Clinical Quality Review Specialist (RN) – Work From Home

HCSC • Richardson, TX

23h • Remote

About The Position

This position is responsible for facilitating member and provider appeals, working closely with Medical Directors and Customer Service to ensure the appeal process meets established guidelines. The role adheres to accreditation and regulatory requirements to meet audit standards and manages individual inventory through appropriate workflow. This is a Remote/Work-From-Home role.

Requirements

• Registered Nurse (RN) with unrestricted license in state of operations
• 5 years combined knowledge of healthcare processes
• Knowledge of managed care processes
• Organizational skills and ability to meet deadlines and manage multiple priorities
• Verbal and written communication skills to include interfacing with staff across organizational lines plus interfacing with members and providers
• PC experience to include Microsoft Word, Access, and Excel

Nice To Haves

• Bachelor’s degree
• Utilization management experience
• Health claims and mainframe system experience
• Experience with internal/external customer relations
• Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards
• Knowledge of state and federal health care and health operations regulations

Responsibilities

• Facilitating member and provider appeals
• Working closely with Medical Directors and Customer Service to ensure appeal process meets established guidelines
• Adhering to accreditation and regulatory requirements to meet audit standards
• Managing individual inventory through appropriate workflow

Benefits

• health and wellness benefits
• 401(k) savings plan
• pension plan
• paid time off
• paid parental leave
• disability insurance
• supplemental life insurance
• employee assistance program
• paid holidays
• tuition reimbursement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level