Quality Review Specialist
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Overview
Compensation
$38-$38/hour
Job Description
Job Title:Quality Review SpecialistLocation:United StatesJob Type:W2 ContractExpected Hours per Week:40 hours per weekSchedule:Monday–Friday, 9:00 AM to 5:00 PM, RemotePay Range:$38 per hourPosition Description:We are seeking an experienced Appeals / Utilization Management Nurse to support the resolution of member and provider appeals in a managed care environment. This role partners closely with Utilization Management, Case Management, and Customer Service teams to ensure appeals are processed in compliance with regulatory, accreditation, and organizational standards while delivering a high level of customer service.What You’ll Do:
- Collaborate with Utilization Management (UM), Case Management (CM), and Customer Service teams to ensure appeals processes meet established guidelines.
- Facilitate end-to-end resolution of member and provider appeals in compliance with state and federal regulations.
- Manage individual appeal inventory using established workflows while meeting required turnaround times.
- Ensure compliance with NCQA, URAC, DOI, and other regulatory and accreditation standards.
- Participate in NCQA and URAC audits, DOI audits, correspondence revisions, and departmental process improvement initiatives.
- Provide data and reporting required for audits, regulatory reviews, and internal stakeholders.
- Facilitate member or member-designee access to appeal files in accordance with federal guidelines.
- Work directly with members and providers to resolve appeals while maintaining superior customer service standards.
- Serve on departmental workgroups and support cross-functional teams.
- Maintain strong working relationships across organizational lines to achieve operational goals.
- Communicate professionally with leadership, peers, members, and providers.
- Maintain strict compliance with HIPAA, Corporate Integrity, Diversity Principles, and all applicable corporate policies.
- Preserve confidentiality of protected health information and company business.
- Communicate workflow updates, trends, and development needs to management; complete special projects as assigned.
- 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 healthcare operations and managed care environments.
- Strong knowledge of NCQA and URAC accreditation standards.
- Knowledge of state and federal healthcare and health operations regulations.
- Strong organizational skills with the ability to manage multiple priorities and deadlines.
- Excellent verbal and written communication skills with internal teams, members, and providers.
- Proficiency in Microsoft Word, Excel, and Access.
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FAQs About Quality Review Specialist Jobs at Epitec, Inc
What is the work location for this position at Epitec, Inc?
This job at Epitec, Inc is located in Albuquerque, NM, according to the details provided by the employer. Some roles may also include multiple work locations depending on the requirement.
What pay range can candidates expect for this role at Epitec, Inc?
Candidates can expect a pay range of $38–$38 per hour for this role.
What employment applies to this position at Epitec, Inc?
The employer has not provided this information. This may be discussed during the hiring process.
What is the process to apply for this position at Epitec, Inc?
You can apply for this role at Epitec, Inc either through Sonara's automated application system, which helps you submit applications 10X faster with minimal effort, or by applying manually using the direct link on the job page.