Illinois Licensed Quality Review Specialist
virtual vocationsDenver, CO
Illinois Licensed Quality Review Specialist
Industries
All Other Outpatient Care CentersAll Other Miscellaneous Ambulatory Health Care ServicesAll Other Insurance Related ActivitiesAbout the role
To enhance customer service and ensure compliance with regulatory standards, the remote Illinois Licensed Quality Review Specialist will manage appeal processes, facilitate resolutions for member and provider appeals, and maintain documentation for audit readiness.
Key responsibilities:
Work closely with Utilization Management, Case Management, and Customer Service to ensure adherence to appeal process guidelines
Facilitate final resolution of member and provider appeals while maintaining compliance with external regulatory standards
Document data for required reporting and ensure audit readiness while managing individual inventory through appropriate workflow
Required qualifications:
Active RN license in good standing
Bachelor's Degree or 4 years of healthcare experience
5 years of experience in utilization management, appeals, claims, and mainframe systems
Knowledge of managed care processes and national accreditation standards, specifically NCQA and URAC
Experience with internal/external customer relations and health operations
Matching similar jobs
JOB OVERVIEW
Experience level
Senior
Location
Denver, CO
Occupation
Quality Control Systems Managers
Industry
All Other Outpatient Care Centers
Posted
yesterday
Tired of running searches?
Rank the roles you'd take once, and matches like these arrive on their own.
CREATE PROFILE (opens in a new tab)