What are the responsibilities and job description for the Clinical Quality Review Specialist position at Blue Cross Blue Shield of IL, MT, NM, OK & TX?
**This is a Work from Home position located in TX, IL, NM**
Job Summary:
This position is responsible for facilitating Member and Provider Appeals; working closely with Customer Service (CS), Provider Telecommunication Center (PTC), external business partners and Medical Management Department (MMD) to ensure appeal process meets established guidelines; adhering to accreditation and regulatory requirements; participating in department initiatives related to NCQA and URAC audits, DOI audits, revision project, audits, and correspondence revision projects; and managing individual inventory through appropriate workflow.
Requirements:
- Registered Nurse (RN) with unrestricted license in state of operations.
- 5 years combine knowledge of healthcare processes.
- Knowledge of managed care processes.
- Organizational skills and ability to meet deadlines and manage multiple priorities.
- Verbal and written communication skills to include interfacing with staff across organizational lines plus interfacing with members and providers.
- PC experience to include Microsoft Word, Access, and Excel.
Preferred Requirements:
- Bachelors degree.
- Utilization management experience.
- Health claims and mainframe system experience.
- Experience with internal/external customer relations.
- Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards.
- Knowledge of state and federal health care and health operations regulations.
- CA
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
Requirements:
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.
If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at 1-866-977-7378 to request reasonable accommodations.
Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "my account" and click on "View your job submissions".