Overview
Job Details
Quality Review Specialist | 5 Years of Experience | Remote | Illinois, Montana, New Mexico, Oklahoma, or Texas | Contract to Hire
Walker Healthforce is seeking a Quality Review Specialist with 5 years of experience to support a healthcare client based out of Illinois, Montana, New Mexico, Oklahoma, or Texas. This is a 6-month contract to hire opportunity.
RATE RANGE: $34 - $36
START DATE: June 23, 2025
HOURS/SCHEDULE: M-F shift 40 hours per week, but mandatory to work holidays (rotating scheduled 3-4 holidays per year) and one weekend every 3rd weekend
WORKER TYPE: Full-Time
CORE REQUIREMENTS:
- Bachelor Degree OR 4 years in health care experience
- 5 years utilization management, appeals, claims, and mainframe system experience
- Experience in health operations
- Experience with internal/external customer relations
- Knowledge of managed care processes
- Knowledge and familiarity with national accreditation standards, specifically National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) standards
- Knowledge of state and federal health care and health operations regulations
- Organizational skills and ability to meet deadlines and manage multiple priorities
- PC proficiency to include Microsoft Word, Access, and Excel
WE CONSIDER IT A BONUS IF YOU ALSO HAVE:
- Registered Nurse (R.N.)
JOB RESPONSIBILITIES:
- Work closely with Full Service Unit (FSU), Provider Telecommunication Center (PTC), and Medical Management Department (MMD) to ensure appeal process meets established guidelines.
- Adhere to accreditation and regulatory requirements to improve customer service and achieve organizational goals related to complaint and appeal resolution.
- Manage individual inventory through appropriate workflow.
- Facilitate final resolution of member and provider appeals.
- Participate in department initiatives related to National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) audits, DOI audits, revision projects, audits, and correspondence revision projects.
- Serve on workgroups.
- Adhere to compliance with external regulatory and accreditation standards.
- Facilitate access to appeal files by members or member designee under federal guidelines.
- Provide data for required reporting.
- Work directly with members and providers to resolve appeals.
- Support other team members in appeal resolution and in fulfilling other department responsibilities.
- Assist in maintaining working relationships across organizational lines.
- Ensure our member/providers requirements are met at all times.
- Communicate and interact effectively and professionally with co-workers, management, customers, etc.
- Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies, and other applicable corporate and departmental policies.
- Maintain complete confidentiality of company business.
- Maintain communication with management regarding developments within areas of assigned responsibilities and perform special projects as required or requested.
WHAT WE OFFER:
- Competitive compensation package
- Weekly pay via Direct Deposit
- Medical, Dental & Vision available
- 401k options
WHY WORK WITH WALKER?
- Access to our top ranked team of recruiting and placement specialists
- Continuous, one-on-one support from a dedicated engagement manager
- Professional resume development and interview preparation
Contact our Recruiting Team today to experience the Walker Healthforce difference!
ABOUT US:
Walker Healthforce is known as the dominant force of performance, precision, expertise, and integrity in the healthcare consulting community! As a certified WMBE, we provide end-to-end healthcare IT and clinical solutions to hospitals, health systems, and payer organizations, including Fortune 100 firms nationwide. We are healthcare experts, we’re custom not commodity and we’ve been exceeding expectations for nearly 20 years. Join forces with us to experience unparalleled results today!
We are an Equal Opportunity Employer committed to a culturally diverse workforce. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, gender identity, disability status or protected veteran status.
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