Clinical Quality Review Specialist (RN) – Work From Home

Enterprise HCM; Richardson (TX); Remote; USD 70,000 - 126,000; Full time

Job summary

HCSC is seeking a dedicated RN to facilitate member and provider appeals, coordinating with Medical Directors and Customer Service to ensure compliant processes while maintaining efficient workflow. The role requires strong communication and organizational abilities and a solid foundation in healthcare operations. This remote position supports the U.S.

market. Compensation ranges from $69,800 to $125,900 annually, with eligibility contingent on experience and location.

Qualifications

• RN license valid in the operating state.
• Minimum 5 years combined healthcare process experience.
• Knowledge of managed care processes.
• Strong organizational skills and ability to meet deadlines.
• Excellent verbal and written communication.

Responsibilities

• Facilitate member and provider appeals with established guidelines.
• Collaborate with Medical Directors and Customer Service to ensure audit-ready processes.
• Manage inventory workflow through appropriate procedures.

Skills

RN License

Healthcare Processes

Managed Care

Organization

Communication Skills

Word

Excel

Access

Education

Bachelor's degree

Job description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

This position is responsible for 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.

JOB REQUIREMENTS

• Registered Nurse (RN) with unrestricted license in state of operations.
• 5 years combine 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.

PREFERRED JOB REQUIREMENTS

• 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.
• Work Hours are 9 AM to 5:30 PM CST Monday through Friday, with occasional late shift coverage and rotating weekends/holidays.

#LI-FW1

#LI-Remote

This is a Remote/Work-From-Home role

Sponsorship is not available

Compensation: $69,800.00 - $125,900.00

Exact compensation may vary based on skills, experience, and location

HCSC Employment Statement

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. We are a drug-free and smoke-free workplace. Employment may be contingent upon successful completion of drug screening in accordance with applicable law.