Illinois Licensed Quality Review Specialist

Job Summary

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