Quality Review Specialist

W3R Consulting; Illinois; On-site; USD 85,000 - 110,000; Full time

Job summary

W3R Consulting in Illinois seeks a Registered Nurse to lead and coordinate healthcare appeals. You will work with Utilization Management, Case Management and Customer Service to ensure appeals meet guidelines and accreditation standards.

The role requires 5 years in UM, appeals, claims, and mainframe systems, plus knowledge of NCQA/URAC and federal health regulations. Strong communication, organization, and ability to handle multiple priorities are essential.

Qualifications

• Active RN license in good standing.
• Bachelor's degree OR 4 years health care experience.
• 5 years in utilization management, appeals, claims and mainframe systems.
• Experience in health operations.
• Experience with internal and external customer relations.
• Knowledge of managed care processes and NCQA/URAC standards; familiarity with state and federal regulations.

Responsibilities

• Collaborate with UM, CM, and CS to ensure appeal processes meet guidelines.
• Adhere to accreditation and regulatory requirements to improve service and resolve appeals.
• Manage individual inventory through appropriate workflow.
• Facilitate final resolution of member and provider appeals.
• Comply with HIPAA and corporate policies.
• Ensure audit readiness and required reporting.
• Maintain confidential handling of all company information.
• Communicate effectively with members, providers, and coworkers.

Skills

Utilization management

Appeals handling

Regulatory compliance

HIPAA compliance

Verbal and written communication

Organizational skills

Deadline management

NCQA/URAC knowledge

Education

Bachelor's degree OR 4 years health care experience

Tools

Microsoft Word

Microsoft Excel

Microsoft Access

Mainframe systems

Job description

Description:

• 1.Work closely with Utilization Management (UM), Case Management (CM) and Customer Service (CS) to ensure appeal process meets established guidelines.


• 2.Adhere to accreditation and regulatory requirements to improve customer service and achieve organizational goals related to complaint and appeal resolution.


• 3.Manage individual inventory through appropriate workflow.


• 4.Facilitate final resolution of member and provider appeals.


• 5. Adhere to compliance with external regulatory and accreditation standards.


• 6.Facilitate access to appeal files by members or member designee under federal guidelines.


• 7 .Appropriately document data for required reporting and ensure audit readiness.


• 8.Work directly with members and providers to resolve appeals.


• 9. Support other team members in appeal resolution and in fulfilling other department responsibilities.


• 10. Assist in maintaining working relationships across organizational lines.


• 11. Ensure our member/providers requirements are met at all times.


• 12. Communicate and interact effectively and professionally with co-workers, management, customers, etc.


• 13. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.


• 14. Maintain complete confidentiality of company business.


• 15. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:

• Applicants must hold an active RN license in good standing.


• Bachelor's Degree OR 4 years in health care experience.


• 5 years utilization management, appeals, claims and mainframe system experience.


• Experience in health operations.


• Experience with internal/external customer relations.


• Knowledge of managed care processes. Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards. Knowledge of state and federal health care and health operations regulations .


• 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 proficiency to include Microsoft Word, Access, and Excel.

PREFERRED JOB REQUIREMENTS:

• Appeals or Utilization management experience.