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Job Requirements of Quality Review Specialist Nurse:
-
Employment Type:
Contractor
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Location:
Chicago, IL (Onsite)
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Quality Review Specialist Nurse
Careers Integrated Resources Inc
Chicago, IL (Onsite)
Contractor
Job Title: Quality Review Specialist Nurse
Location: Fully Remote must reside in - TX/IL/NM/OK/MT/TN
Duration: 6 months+ Contract (Possible Extension)
Pay Rate: $42/hr. on W2
Job Summary:
Responsibilities:
Required Qualifications:
Location: Fully Remote must reside in - TX/IL/NM/OK/MT/TN
Duration: 6 months+ Contract (Possible Extension)
Pay Rate: $42/hr. on W2
Job Summary:
- This is a full-time, Monday–Friday position (40 hours/week). The role requires working 3–4 holidays per year on a rotating schedule and one weekend every third weekend after training. The position is fully remote within any of the company’s six approved states.
- The Appeals Specialist is responsible for the timely and accurate review, processing, and resolution of member and provider appeals. This role works closely with internal departments to ensure compliance with regulatory, accreditation, and organizational standards while delivering high-quality service.
Responsibilities:
- Collaborate with FSU, PTC, and MMD to ensure appeals are processed according to guidelines.
- Adhere to accreditation and regulatory requirements (NCQA, URAC, DOI).
- Manage assigned inventory and workflow efficiently.
- Facilitate final resolution of member and provider appeals.
- Participate in audits, revision projects, and departmental initiatives.
- Serve on internal workgroups as assigned.
- Ensure compliance with all regulatory and accreditation standards.
- Facilitate access to appeal files under federal guidelines.
- Provide data and information for required reporting.
- Work directly with members and providers to resolve appeal issues.
- Support teammates with appeal resolutions and departmental tasks.
- Maintain effective working relationships across departments.
- Ensure member and provider needs are met at all times.
- Communicate professionally with internal and external stakeholders.
- Maintain confidentiality and comply with HIPAA and corporate policies.
- Update management on progress and assist with special projects.
Required Qualifications:
- Bachelor’s degree OR 4 years of healthcare experience.
- Minimum 5 years of experience in utilization management, appeals, claims, or mainframe systems.
- Experience in health operations and customer relations.
- Knowledge of managed care processes.
- Familiarity with NCQA and URAC accreditation standards.
- Understanding of state and federal healthcare regulations.
- Strong organizational and time-management skills.
- Excellent verbal and written communication skills.
- Proficiency in Microsoft Word, Access, and Excel.
- Preferred Qualifications
- Registered Nurse (RN).
- Appeals and/or Utilization Management experience.
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