Clinical Quality Review Specialist (RN) – Work From Home

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

Job summary

Health Care Service Corporation is seeking an RN to facilitate member and provider appeals and collaborate with Medical Directors and Customer Service to ensure the appeals process meets guidelines. The role emphasizes adherence to accreditation and regulatory requirements and managing inventory through appropriate workflows.

This remote position offers a stable schedule with potential late shifts and rotating holidays.

Qualifications

• Unrestricted RN license in state of operations.
• 5 years combined knowledge of healthcare processes.
• Knowledge of managed care processes.
• Strong organizational skills and ability to meet deadlines.
• Verbal and written communication with staff, members, and providers.
• Proficiency in Word, Access, and Excel.

Responsibilities

• Facilitate member and provider appeals.
• Coordinate with Medical Directors and Customer Service to ensure appeals meet guidelines.
• Adhere to accreditation and regulatory requirements for audits.
• Manage inventory through appropriate workflow.

Skills

Communication

Organizational skills

Managed care

Multitasking

MS Word

Education

RN license

Bachelor's degree

Tools

Microsoft Word

Microsoft Access

Microsoft 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 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

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

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.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

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

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.

Base Pay Range

$69,800.00 - $125,900.00

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