Utilization Review Nurse

Innovative Systems Group; Chicago (IL); On-site; USD 65,000 - 90,000; Full time

Job summary

Innovative Systems Group in Chicago seeks a Healthcare Appeals Specialist to collaborate with Utilization Management, Case Management, and Customer Service to ensure compliant appeal processes.

You will adhere to accreditation standards, manage workflow, facilitate final resolutions for member and provider appeals, and participate in audits. Maintain confidentiality and coordinate with management on special projects as needed.

Responsibilities

• Work closely with Utilization Management (UM), Case Management (CM), and Customer Service (CS) to ensure the appeal process meets established guidelines.
• Adhere to accreditation and regulatory requirements to improve customer service and achieve organizational goals related to complaint and appeal resolution.
• Manage individual inventory through the appropriate workflow.
• Facilitate the final resolution of member and provider appeals.
• Participate in department initiatives related to NCQA and URAC audits, DOI audits, revision projects, audits, and correspondence revision projects.
• Serve on workgroups.
• Adhere to external regulatory and accreditation standards.
• Facilitate access to appeal files by members or their designees in accordance with federal guidelines.
• Provide data for required reporting.
• Work directly with members and providers to resolve appeals.
• Support other team members in appeal resolution and in fulfilling other department responsibilities.
• Assist in maintaining working relationships across organizational lines.
• Ensure member and provider requirements are met at all times.
• Communicate and interact effectively and professionally with co-workers, management, customers, and others.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies, and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding developments within assigned areas of responsibility and perform special projects as required or requested.

Job description

• Work closely with Utilization Management (UM), Case Management (CM), and Customer Service (CS) to ensure the appeal process meets established guidelines.
• Adhere to accreditation and regulatory requirements to improve customer service and achieve organizational goals related to complaint and appeal resolution.
• Manage individual inventory through the appropriate workflow.
• Facilitate the final resolution of member and provider appeals.
• Participate in department initiatives related to NCQA and URAC audits, DOI audits, revision projects, audits, and correspondence revision projects.
• Serve on workgroups.
• Adhere to external regulatory and accreditation standards.
• Facilitate access to appeal files by members or their designees in accordance with federal guidelines.
• Provide data for required reporting.
• Work directly with members and providers to resolve appeals.
• Support other team members in appeal resolution and in fulfilling other department responsibilities.
• Assist in maintaining working relationships across organizational lines.
• Ensure member and provider requirements are met at all times.
• Communicate and interact effectively and professionally with co-workers, management, customers, and others.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies, and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding developments within assigned areas of responsibility and perform special projects as required or requested.