Quality Review Specialist 27103
One of the largest health insurers in the nation is focused on continuously building an industry-defining, world-class IT capability. Healthcare is forever evolving, especially due to emerging technologies, making this a great experience to add to your resume. Come join their winning team!
This contract role as a Quality Review Specialist in Chicago, IL will support Government Appeals. This role is remote until a return to work is established.
• Work closely with Customer Service and Internal Medical Directors to ensure 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 appropriate workflow.
• Facilitate final resolution of member and provider appeals.
• Participate in department initiatives related to NCQA and URAC audits, DOI audits, revision project, audits, and correspondence revision projects.
• Serve on workgroups.
• Adhere to compliance with external regulatory and accreditation standards.
• Facilitate access to appeal files by members or member designee under 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 our customers’ requirements are met at all times.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• 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 development within areas of assigned responsibilities and perform special projects as required or requested.
• Registered Nurse (RN)
• Bachelor’s degree OR 4 years in health care experience. Can have an Associate’s in nursing with 4 years in health care 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.
• Ability to multi-task
• 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:
• Utilization management experience.
Solving IT is pleased to offer a rich benefit plan to our W2 employees. We offer five health plan options and a PPO dental plan through Blue Cross Blue Shield, Term Life/AD&D Insurance, and 401(k) Savings Plan. Solving IT subsidizes the health and dental premium for the employee.
As you continue to develop your skills and experience, Solving IT will work with your changing preferences to match you with rewarding projects. Our unrivaled reputation for quality is demonstrated through our Inavero Best of Staffing award that was won due to the feedback from our own clients and candidates. We also love to socialize and have fun so we have regularly scheduled parties and events for you to unwind and network with fellow consultants.
Whether you are searching for your next challenge or just looking to stay on top of market trends, Solving IT is committed to help position you appropriately. By leveraging the latest market and compensation data available, you can rest assured that you are getting more than just an informed opinion. You are getting the Solving IT Experience.