Job Description

Job Description

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.
• Utilization management experience.

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