Quality Review Nurse

Location: Remote in IL, TX, NM, OK, or MT

Job Type: W2 Contract

Expected hours per week: 40 hours per week

Schedule: Monday-Friday with required participation in a rotating holiday schedule (3–4 holidays per year) and one weekend every third weekend

Pay: $42 per hour

This role supports the end-to-end appeals process to ensure timely, accurate, and compliant resolution of member and provider appeals. You will collaborate across multiple operational teams, uphold regulatory and accreditation standards, and contribute to continuous improvement initiatives. This is a full-time, Monday–Friday position (40 hours/week) with required participation in a rotating holiday schedule (3–4 holidays per year) and one weekend every third weekend.

The position is fully remote within our five-state service area. Compensation aligns with conversion salary guidelines.

• Collaborate across operational teams including the Full-Service Unit (FSU), Provider Telecommunication Center (PTC), and Medical Management Department (MMD) to ensure appeals follow established guidelines.
• Ensure compliance with accreditation and regulatory requirements to support organizational goals for complaint and appeal resolution.
• Manage individual appeal inventory through established workflows to meet timeliness and quality standards.
• Facilitate final resolution of member and provider appeals, ensuring clear communication and accurate documentation.
• Participate in departmental initiatives including NCQA and URAC audits, DOI audits, revision projects, and correspondence updates.
• Serve on cross-functional work groups to support process improvement and operational alignment.
• Maintain compliance with external regulatory and accreditation standards at all times.
• Coordinate access to appeal files for members or authorized representatives in accordance with federal guidelines.
• Provide data and reporting as required for internal and external stakeholders.
• Engage directly with members and providers to resolve appeal issues and ensure a positive service experience.
• Support team members in appeal resolution and broader departmental responsibilities.
• Foster strong working relationships across organizational lines to support operational effectiveness.
• Ensure member and provider needs are met with professionalism and accuracy.
• Communicate effectively and professionally with colleagues, leadership, members, and providers.
• Adhere to HIPAA, Diversity Principles, Corporate Integrity, and Compliance Program policies as well as all corporate and departmental requirements.
• Maintain strict confidentiality of all company and member information.
• Provide updates to management on work progress and participate in special projects as assigned.

• Registered Nurse (RN) with a Bachelor’s degree
• Minimum 5 years of experience in utilization management, appeals, claims, and mainframe systems
• Experience in health operations and working with internal/external customers
• Knowledge of managed care processes and health plan operations
• Familiarity with NCQA and URAC accreditation standards
• Understanding of state and federal healthcare regulations
• Strong organizational skills with the ability to manage multiple priorities and meet deadlines
• Excellent verbal and written communication skills, including the ability to work across departments and interact with members and providers
• Proficiency in Microsoft Word, Access, and Excel

• Appeals and/or utilization management experience