Clinical Quality Review Spec

Location: Chicago, ILRelocation Provided: NoEducation Required: Not IndicatedExperience Required: Not IndicatedPosition Description:BASIC FUNCTION:This position is responsible for facilitating Member and Provider Appeals; working closely with Full Service Unit (FSU), Provider Telecommunication Center (PTC), and Medical Management Department (MMD) to ensure appeal process meets established guidelines; adhering to accreditation and regulatory requirements; participating in department initiatives related to NCQA and URAC audits, DOI audits, revision project, audits, and correspondence revision projects; and managing individual inventory through appropriate workflow. JOB REQUIREMENTS: 1) Registered Nurse (RN) with unrestricted license in state of operations; 2) 5 years health claims and mainframe system experience; 3) Previous experience with internal/external customer relations; 4) Knowledge of managed care processes; 5) Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards; 6) Knowledge of state and federal health care and health operations regulations; 7) Effective organizational skills, with the ability to meet deadlines and manage multiple priorities; 8) Effective verbal and written communication skills to include interfacing with staff across organizational lines plus interfacing with members and providers; 9) PC experience with Microsoft Word, Access, and Excel.PREFERRED JOB REQUIREMENTS: 1) Bachelor's Degree; 2) Utilization management experience..