Clinical Quality Review Specialist, RN

This is a fully remote position, open to applicants in Texas.

📋 Description

• Oversee member and provider appeals.

• Collaborate closely with Medical Directors and Customer Service teams.

• Ensure that the appeal process aligns with established guidelines.

• Comply with accreditation and regulatory standards to uphold audit requirements.

• Manage individual inventory using the appropriate workflow.

⛳️ Requirements

• Must be a Registered Nurse (RN) with an unrestricted license in the state of operation.

• Have a minimum of 5 years of combined experience in healthcare processes.

• Familiarity with managed care processes is essential.

• Strong organizational skills with the ability to meet deadlines and handle multiple priorities.

• Excellent verbal and written communication skills, capable of interacting with staff across various organizational levels, members, and providers.

• Proficient in PC applications, including Microsoft Word, Access, and Excel.

• Experience in utilization management is preferred.

• Preference for candidates with health claims and mainframe system experience.

• Previous experience in internal/external customer relations is preferred.

• Knowledge of national accreditation standards, particularly NCQA and URAC standards, is preferred.

• Understanding of state and federal healthcare regulations is preferred.

• Must have work authorization without the need for sponsorship; sponsorship is not available.

• Availability to work from 9 AM to 5:30 PM CST Monday through Friday, with the potential for occasional late shift coverage and rotating weekends/holidays.

🏝️ Benefits

• Tailored development plans and opportunities for professional growth.

• Comprehensive health and wellness benefits.

• 401(k) savings plan.

• Pension plan.

• Paid time off.

• Paid parental leave.

• Disability insurance.

• Supplemental life insurance.

• Employee assistance program.

• Paid holidays.

• Tuition reimbursement.

• Annual incentive bonus plan.

• Additional incentives.