Clinical Quality Review Spec

Health Care Service Corporation
life insurance, parental leave, paid time off, paid holidays, tuition reimbursement, 401(k)
United States, Illinois, Chicago
Sep 03, 2025
At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. 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 CMS audits, DOI audits, revision project, audits, and correspondence revision projects; and managing individual inventory through appropriate workflow. Also, conducting audits as well as monitoring ongoing quality improvement activities within the utilization management team; analyzing compliance with department policies, regulatory and accrediting requirements, and preparing reports for management presentation to internal ancillary departments and committees; and serving as a resource to internal ancillary departments on quality and utilization issues and contributing to accreditation survey process. 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. Knowledge of UM/CM policies and practices. Knowledge or experience of Post-Acute Reviews. Quality Improvement experience. Analytical Skills. Utilization Management Background. Participate in department initiatives related to CMS audits, revision project, audits, and correspondence revision projects. Work closely with CS, manager, appeals, UM and external business partners to ensure UM/appeal process meets established guidelines. 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 CMS standards. Knowledge of state and federal health care and health operations regulations. Telecommute: This is a Telecommute (Remote) role: Must reside within 250 miles of the office or anywhere within the posted state. #LI-SG1 #LI-REMOTE Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! Pay Transparency Statement: At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards. The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plansubject to the terms and the conditions of the plan. HCSC Employment Statement: We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Base Pay Range$60,300.00 - $133,400.00 Exact compensation may vary based on skills, experience, and location.