What are the responsibilities and job description for the Utilization Review Nurse position at Innovative Systems Group?
Job Title: Quality Review Specialist
Location: Remote in IL, TX, NM, OK
Duration: 6 months contract to hire
Pay: $46.50/hr on W2 or $93k conversion salary
Description:
This is a M-F shift 40 hours per week, but mandatory to work holidays (rotating scheduled 3-4 holidays per year) and one weekend every 3rd weekend once training has been completed
pay should align to conversion salary
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.
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.
Salary : $2,000 - $93,000