Clinical Quality Review Specialist (RN) – Work From Home

Health Care Service Corp.; Richardson (TX); Remote; USD 70,000 - 126,000; Full time

Job summary

Health Care Service Corporation (HCSC) seeks a registered nurse to facilitate member and provider appeals, coordinating with Medical Directors and Customer Service to ensure compliant processes. The role requires adherence to accreditation and regulatory standards and managing inventory through established workflows.

The position is remote with work hours 9 AM–5:30 PM CST, offering a competitive pay range and a comprehensive rewards package. Sponsorship is not available.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Registered Nurse license (RN)

5 years healthcare processes

Managed care processes

Organizational skills

Verbal and written communication

Word, Access, Excel

Education

Bachelor’s degree

Tools

Microsoft Word

Access

Excel

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.

Job Summary

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 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

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

This is a Remote/Work-From-Home role.

Work Location

This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii.

Pay Transparency Statement

Pay Transparency Statement: At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From 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, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

Base Pay Range $69,800.00 - $125,900.00 Exact compensation may vary based on skills, experience, and location.

This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

Sponsorship

Sponsorship is not available.

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.

Company Culture

For more than 80 years, HCSC has been dedicated to expanding access to high-quality, cost-effective health care and equipping our members with information and tools to make the best health care decisions for themselves and their families. As an industry leader, HCSC also has been helping to make the health care system work better for all Americans. To remain a leader, we offer compelling careers that encourage resourcefulness, strategic thought and empower you to make a difference in the lives of our members and their communities.

Today, with the industry at an important crossroad, HCSC is reimagining health care and looking for original thinkers who aren’t afraid to make innovative contributions.

We are an Equal Opportunity Employment employer dedicated to workforce diversity and a drug-free and smoke-free workplace.

Accommodations

If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at 1-866-977-7378 to request reasonable accommodations.

Learn more about HCSC, our commitment to our members and the opportunity you’ll have to improve health care delivery in an open, collaborative environment.