Quality Review Specialist

Job Title: Quality Review Specialist
Job Location: Downers Grove, IL (Fully Remote must reside in - TX/IL/NM/OK/MT/TN)
Job Duration: 5-6 months Contract to Hire 
Payrate: $42 - $45/ hr. on w2

Job Summary:

• 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 client 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 Education:

• Bachelor’s degree OR 4 years of healthcare experience.

Required Experience:

• Minimum 5 years of experience in utilization management, appeals, claims, or mainframe systems.
• Experience in health operations and customer relations.
• Appeals and/or Utilization Management experience.

Knowledge, Skills, and Abilities:

• 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.

Work Schedule:

• 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.
• Pay will align with the expected conversion salary.