Remote Quality Review Specialist 30223

Company: Solving IT
Location: Atlanta
Posted on: June 24, 2025

Job Description:

One of the largest health insurers in the nation is focused on continuously building an industry-defining, world-class IT capability. Healthcare is forever evolving, especially due to emerging technologies, making this a great experience to add to your resume. Come join their winning team! This contract to hire role as a Remote Quality Review Specialist in Richardson, TX is responsible for working closely with the Full service Unit (FSU), Provider Telecommunication Center (PTC), and Medical Management Department (MMD) to ensure appeal process meets established guidelines. Pay Rate: $35 - $38 per hour Responsibilities: • Work closely with the 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 NCQA and URAC audits, DOI audits, revision project, 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 that 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 development within areas of assigned responsibilities and perform special projects as required or requested. Job 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 of national accreditation standards, specifically NCQA and URAC standards. • Knowledge of state and federal health care and health operations regulations. • 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 proficiency to include Microsoft Word, Access, and Excel. Preferred Job Requirements: • Registered (R.N.) Utilization management experience. Benefits : Solving IT, a Woman and LGBTQ owned and operated organization is thrilled to provide a comprehensive benefit package to all our W2 employees and their families, regardless of gender. We are proud to offer five diverse health plan options as well as a PPO dental plan through Blue Cross Blue Shield, Term Life/AD&D Insurance, and a 401(k) Savings Plan. Solving IT covers a portion of the health and dental premiums for our employees. As you progress in your professional journey, Solving IT is dedicated to accommodating your evolving preferences and matching you with fulfilling projects. We champion equality and embrace diversity in all its forms. Creating an atmosphere that encourages varied perspectives to collaborate fosters personal development, strengthens team unity, and contributes to the overall success of the organization! Whether you're seeking your next career challenge or aiming to stay abreast of industry trends, Solving IT is committed to supporting your career advancement. We actively encourage applications from all backgrounds and utilize the most up-to-date market insights and compensation data to ensure that you receive not just advice, but the complete Solving IT Experience.

Keywords: Solving IT, East Point , Remote Quality Review Specialist 30223, Healthcare , Atlanta, Georgia