Utilization Review Nurse (LPN)

w3r Consulting; Downers Grove (IL); Remote; USD 1,000; Full time

Job summary

A leading company in healthcare staffing is seeking a Quality Review Specialist in Downers Grove, IL. The role focuses on managing appeal processes within compliance guidelines, requiring strong communication and organizational skills. Ideal candidates will hold a bachelor's degree and possess significant experience in healthcare operations and appeal management.

Qualifications

• 5+ years in utilization management, appeals, claims, and mainframe systems.
• Strong knowledge of health operations and managed care.
• Familiarity with healthcare regulations.

Responsibilities

• Manage and resolve member and provider appeals efficiently.
• Ensure compliance with NCQA, URAC, and federal guidelines.
• Support audits and process improvements.

Skills

Communication

Organization

PC skills

Education

Bachelor’s degree

Tools

Word

Access

Excel

Job description

This range is provided by w3r Consulting. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$36.00/hr - $36.00/hr

Direct message the job poster from w3r Consulting

Senior Healthcare Recruiter Passionate About People ️, Dedicated to Healthcare | Senior Recruiter Building the Future of Healthcare Teams

Job Title: Quality Review Specialist

Location: Downers Grove, IL (Remote but looking candidates in Illinois, Texas, Oklahoma, New Mexico & Montana)

Contract: 6 Months

Schedule: M-F (8 am to 5pm)

Position Summary:

The Appeals Specialist works with the Full-Service Unit (FSU), Provider Telecommunication Center (PTC), and Medical Management Department (MMD) to ensure appeal processes follow established guidelines and regulatory standards. This role manages appeal cases, resolves member and provider appeals promptly, and supports audits and compliance initiatives.

Key Responsibilities:

• Collaborate with FSU, PTC, and MMD to ensure appeal guidelines and standards are met.
• Manage and resolve member and provider appeals efficiently.
• Ensure compliance with NCQA, URAC, DOI, and federal guidelines.
• Support audits, data reporting, and process improvements.
• Maintain strong communication with members, providers, and internal teams.
• Uphold confidentiality and comply with HIPAA and company policies.

Requirements:

• Bachelor’s degree or 4 years of healthcare experience.
• 5+ years in utilization management, appeals, claims, and mainframe systems.
• Strong knowledge of health operations, managed care, and accreditation standards.
• Familiarity with state and federal healthcare regulations.
• Excellent communication, organization, and PC skills (Word, Access, Excel).

Preferred:

• Registered Nurse (R.N.) license.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Contract

Job function

• Job function

  Other

• Industries

  Insurance

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