Clinical Quality Review Spec

1 month ago

Richardson, United States Health Care Service Corporation Full time

At HCSC, we consider our employees the cornerstone of our business and the foundation to our success. We enable employees to craft their career with curated development plans that set their learning path to a rewarding and fulfilling career.

Come join us and be part of a purpose driven company who is invested in your future

Job Summary

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.

TELECOMMUTE WORK:

JOB REQUIREMENTS:

  • Registered Nurse (RN) with unrestricted license in state of operations.
  • 5 years combine 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 to include interfacing with staff across organizational lines plus interfacing with members and providers.
  • PC experience to include Microsoft Word, Access, and Excel.
PREFERRED JOB REQUIREMENTS:
  • Bachelor's degree.
  • Utilization management experience.
  • Health claims and mainframe system experience.
  • Experience with internal/external customer relations.
  • Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards.
  • Knowledge of state and federal health care and health operations regulations.

*CA

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HCSC Employment Statement:

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

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