Clinical Quality Review Specialist (RN) – Work From Home

HCSC Group; Richardson (TX); Remote; USD 70.000 - 126.000; Vollzeit

Zusammenfassung

HCSC is seeking an experienced Registered Nurse to facilitate member and provider appeals and ensure processes meet guidelines and audit standards. You will partner with Medical Directors and Customer Service to drive quality care while managing workflow and inventory.

The role requires a valid RN license, at least 5 years of healthcare experience, and knowledge of managed care. This is a remote/work-from-home position with standard CST hours and occasional time shifts.

Qualifikationen

• 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.

Aufgaben

• Facilitate member and provider appeals; collaborate with Medical Directors and Customer Service to ensure guidelines are met.
• Adhere to accreditation and regulatory requirements to meet audit standards.
• Manage individual inventory through appropriate workflow.
• Communicate effectively with staff across organizational lines, members, and providers.

Kenntnisse

Communication

Organizational skills

Multitasking

Ausbildung

Registered Nurse license

Bachelor’s degree

Tools

Microsoft Word

Microsoft Access

Microsoft Excel

Jobbeschreibung

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.

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.

To learn more about available benefits, please click https://careers.hcsc.com/totalrewards.