Quality Review Specialist - 038109CS

Basic Function:


This position is responsible for coordinating appeals/grievances and complaints for all lines of business; reporting, monitoring, scheduling and facilitating appeals according to regulatory requirements including  Department of Insurance, DOL-ERISA URAC and NCQA; acting as decision maker ensuring adherence to
requirements, analyzing appeals data according to corporate quality improvement performance data; and identifying areas of improvement to initial denials and appeals.

 

Job Requirements:


1)  Current unrestricted RN license in good standing in Illinois;  2)  3 years clinical experience;  3)  2 years experience with utilization review or managed care quality assurance experience; 4)  2 years of experience in Utilization Management or audit;  5)  Demonstrated experience in processing appeals, denials or grievances under specific regulatory or accreditation requirements;  6)  Ability to work alone in a fast paced, demanding environment, while impacting members;  7)Demonstrated experience with associated state and federal guidelines and regulations;  8)  Verbal and written communication skills and facilitating skills;  9)  Demonstrated experience setting goals and monitoring work flow with minimal supervision;  10) Ability to deal with internal/external customers, including representatives of DOI and Medicare in a rapport developing manner;  11)  Must be detail oriented and have excellent organizational skills.

 

Preferred Job Requirements:


1)  Demonstrated experience with grievance and appeal processing;  2)  Demonstrated experience with BlueCross BlueShield claims, image and other BlueChip applications used for documentation;  3)  Demonstrated experience with Microsoft applications, including Word, Access, Excel;  4)  BSN, BS/BA, or Bachelor's Degree