What are the responsibilities and job description for the Quality Review Specialist (RN or LPN/LVN) position at Innovative Systems Group?
Contract-to-hire
Contract: 08/17/2026 to 02/21/2027
Remote in the US except NY, CA, and AK
Job Description:
Applicants must hold an active RN or LPN/LVN license in good standing.
This is a M-F shift 40 hours per week, with MANDATORY holiday and weekend rotations.
Holidays rotation scheduled 3-4 holidays per year and one weekend every 3rd weekend.
Fully remote opportunity available to applicants in any of our U.S. States except NY, CA, and AK
1. Work closely with Utilization Management (UM), Case Management (CM), and Customer Service (CS) to ensure the appeal process meets established guidelines.
2. Adhere to accreditation and regulatory requirements to improve customer service and achieve organizational goals related to complaint and appeal resolution.
3. Manage individual inventory through the appropriate workflow.
4. Facilitate the final resolution of member and provider appeals.
5. Participate in department initiatives related to NCQA and URAC audits, DOI audits, revision projects, audits, and correspondence revision projects.
6. Serve on workgroups.
7. Adhere to external regulatory and accreditation standards.
8. Facilitate access to appeal files by members or their designees in accordance with federal guidelines.
9. Provide data for required reporting.
10. Work directly with members and providers to resolve appeals.
11. Support other team members in appeal resolution and in fulfilling other department responsibilities.
12. Assist in maintaining working relationships across organizational lines.
13. Ensure member and provider requirements are met at all times.
14. Communicate and interact effectively and professionally with co-workers, management, customers, and others.
15. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies, and other applicable corporate and departmental policies.
16. Maintain complete confidentiality of company business.
17. Maintain communication with management regarding developments within assigned areas of responsibility and perform special projects as required or requested.
JOB REQUIREMENTS
* Applicants must hold an active RN or LPN/LVN license in good standing.
* Bachelor's degree or 4 years of healthcare experience.
* 5 years of utilization management, appeals, claims, and mainframe system experience.
* Experience in health operations.
* Experience with internal and external customer relations.
* Knowledge of managed care processes.
* Knowledge and familiarity with national accreditation standards, specifically NCQA and URAC standards.
* Knowledge of state and federal healthcare and health operations regulations.
* Strong organizational skills with the ability to meet deadlines and manage multiple priorities.
* Strong verbal and written communication skills, including the ability to interface with staff across organizational lines, as well as members and providers.
* Proficiency in Microsoft Word, Access, and Excel.
PREFERRED JOB REQUIREMENTS
* Appeals or Utilization Management experience.