Remote RN: Clinical Quality & Appeals Specialist

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

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.