Clinical Quality Review Specialist, RN

Job not on LinkedIn

🔥 2 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $69.8k - $125.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Health Care Service Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Health Care Service Corporation is an independent licensee of the Blue Cross Blue Shield Association, serving nearly 23 million people across the United States with a wide range of health benefit solutions. The company provides health coverage options for various groups, including employers, individuals, families, as well as Medicare and Medicaid plans. In addition to health insurance, HCSC offers services such as pharmacy solutions, life and dental insurance, and health data technology. With nearly a century of experience, HCSC is dedicated to improving access to quality care, enhancing health outcomes, and reducing costs while maintaining a deep commitment to its members and local communities.

📋 Description

• Facilitate member and provider appeals • Work closely with Medical Directors and Customer Service • Ensure the appeal process meets established guidelines • Adhere to accreditation and regulatory requirements to meet audit standards • Manage individual inventory through appropriate workflow

🎯 Requirements

• Registered Nurse (RN) with unrestricted license in state of operations • 5 years combined knowledge of healthcare processes • Knowledge of managed care processes • Organizational skills and ability to meet deadlines and manage multiple priorities • Verbal and written communication skills, including interfacing with staff across organizational lines, members, and providers • PC experience including Microsoft Word, Access, and Excel • Utilization management experience preferred • Health claims and mainframe system experience preferred • Experience with internal/external customer relations preferred • Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards preferred • Knowledge of state and federal health care and health operations regulations preferred • Work authorization without sponsorship; sponsorship is not available • Ability to work 9 AM to 5:30 PM CST Monday through Friday, with occasional late shift coverage and rotating weekends/holidays

🏖️ Benefits

• Curated development plans and professional development opportunities • Health and wellness benefits • 401(k) savings plan • Pension plan • Paid time off • Paid parental leave • Disability insurance • Supplemental life insurance • Employee assistance program • Paid holidays • Tuition reimbursement • Annual incentive bonus plan • Other incentives