Utilization Review Nurse

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<p>Job Title: Quality Review Specialist</p><p>Location: Remote in IL, TX, NM, OK</p><p>Duration: 6+ months contract to hire</p><p>Pay: $46.50/hr on W2 or $93k conversion salary</p><p><br></p><p><strong>Description:</strong></p><p><strong><em>This is a M-F shift 40 hours per week, but mandatory to work holidays (rotating scheduled 3-4 holidays per year) and one weekend every 3rd weekend once training has been completed</em></strong></p><p><strong><em>pay should align to conversion salary</em></strong></p><p>1. Work closely with Utilization Management (UM), Case Management (CM), and Customer Service (CS) to ensure the appeal process meets established guidelines.</p><p>2. Adhere to accreditation and regulatory requirements to improve customer service and achieve organizational goals related to complaint and appeal resolution.</p><p>3. Manage individual inventory through the appropriate workflow.</p><p>4. Facilitate the final resolution of member and provider appeals.</p><p>5. Participate in department initiatives related to NCQA and URAC audits, DOI audits, revision projects, audits, and correspondence revision projects.</p><p>6. Serve on workgroups.</p><p>7. Adhere to external regulatory and accreditation standards.</p><p>8. Facilitate access to appeal files by members or their designees in accordance with federal guidelines.</p><p>9. Provide data for required reporting.</p><p>10. Work directly with members and providers to resolve appeals.</p><p><br></p><p><strong>Job Requirements</strong></p><p>* Applicants must hold an active RN or LPN/LVN license in good standing.</p><p>* Bachelor's degree <strong>or</strong> 4 years of healthcare experience.</p><p>* 5 years of utilization management, appeals, claims, and mainframe system experience.</p><p>* Experience in health operations.</p><p>* Experience with internal and external customer relations.</p><p>* Knowledge of managed care processes.</p><p>* Knowledge and familiarity with national accreditation standards, specifically NCQA and URAC standards.</p><p>* Knowledge of state and federal healthcare and health operations regulations.</p><p>* Strong organizational skills with the ability to meet deadlines and manage multiple priorities.</p><p>* Strong verbal and written communication skills, including the ability to interface with staff across organizational lines, as well as members and providers.</p><p>* Proficiency in Microsoft Word, Access, and Excel.</p><p><br></p><p><strong>Preferred Job Requirements</strong></p><p>* Appeals or Utilization Management experience.</p><p><br></p>

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