Quality Review Specialist

w3r Consulting; Illinois; On-site; USD 70,000 - 100,000; Full time

Job summary

w3r Consulting is seeking a dedicated Appeals Specialist to manage and resolve member and provider appeals within a regulated healthcare environment. You will ensure timely resolutions, maintain thorough documentation, and collaborate across UM, CM, and CS teams.

The role requires strong communication, organizational, and multitasking skills, with a focus on HIPAA, NCQA, URAC, and regulatory compliance. Illinois-based operations emphasize accuracy and audit readiness.

Qualifications

• Bachelor's degree or 4 years of healthcare experience.
• 5 years of experience in Utilization Management, appeals, claims, and mainframe systems.
• Knowledge of managed care, healthcare operations, and regulatory requirements.
• Strong communication, organizational, and multitasking skills.
• Proficiency in Microsoft Word, Excel, and Access.

Responsibilities

• Manage assigned appeal inventory and ensure timely resolution.
• Review and resolve member and provider appeals.
• Collaborate with Utilization Management (UM), Case Management (CM), and Customer Service (CS).
• Communicate with members and providers regarding appeal outcomes.
• Maintain accurate documentation, reporting, and audit readiness.
• Ensure compliance with HIPAA, NCQA, URAC, and state and federal regulations.

Skills

Strong communication

Organizational skills

Multitasking

Regulatory understanding

Education

Bachelor's degree / 4 years healthcare experience

Tools

Microsoft Word

Microsoft Excel

Access

Job description

Responsible for managing and resolving member and provider appeals while ensuring compliance with healthcare regulations, accreditation standards, and organizational guidelines.

Key Responsibilities:

• Manage assigned appeal inventory and ensure timely resolution.
• Review and resolve member and provider appeals.
• Collaborate with Utilization Management (UM), Case Management (CM), and Customer Service (CS).
• Communicate with members and providers regarding appeal outcomes.
• Maintain accurate documentation, reporting, and audit readiness.
• Ensure compliance with HIPAA, NCQA, URAC, and state and federal regulations.

Required Qualifications:

• Bachelor's degree or 4 years of healthcare experience.
• 5 years of experience in Utilization Management, appeals, claims, and mainframe systems.
• Knowledge of managed care, healthcare operations, and regulatory requirements.
• Strong communication, organizational, and multitasking skills.
• Proficiency in Microsoft Word, Excel, and Access.