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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 be responsible for supporting Government appeals. Working closely with Customer Service and Internal Medical Directors to ensure appeal process meets established guidelines. Additionally, adhere to accreditation and regulatory requirements to improve customer service and achieve organizational goals related to complaint and appeal resolution and more, see below. Responsibilities:
- 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 always met.
- 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.
- 5 years claims and mainframe system 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.
- Utilization management experience.