This is a M-F shift 40 hours per week, with MANDATORY holiday and weekend rotations. Holidays rotation scheduled 3-4 holidays per year and one weekend every 3rd weekend.

Fully remote opportunity available to applicants in any of our U.S. States except NY, CA, and AK

Job Responsibilities

- Work closely with Utilization Management (UM), Case Management (CM), and Customer Service (CS) to ensure the 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 the appropriate workflow.
- Facilitate the final resolution of member and provider appeals.
- Participate in department initiatives related to NCQA and URAC audits, Department of Insurance (DOI) audits, revision projects, audits, and correspondence revision projects.
- Serve on departmental workgroups.
- Ensure compliance with external regulatory and accreditation standards.
- Facilitate access to appeal files by members or their designated representatives in accordance with federal guidelines.
- Provide data for required reporting.
- Work directly with members and providers to resolve appeals.
- Support other team members in appeal resolution and assist in fulfilling additional departmental responsibilities.
- Assist in maintaining effective working relationships across organizational lines.
- Ensure member and provider requirements are met at all times.




- Communicate and interact effectively and professionally with co-workers, management, members, providers, and customers.
- Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies, and all applicable corporate and departmental policies.
- Maintain complete confidentiality of company business.
- Maintain ongoing communication with management regarding assigned responsibilities and perform special projects as required or requested.

Required Qualifications
- Active RN or LPN/LVN license in valuable standing.
- Bachelor's degree or four (4) years of healthcare experience.
- Five (5) years of experience in Utilization Management, Appeals, Claims, and mainframe systems.
- Experience in health operations.
- Experience with internal and external customer relations.
- Knowledge of managed care processes.
- Knowledge and familiarity with national accreditation standards, specifically NCQA and URAC.
- Knowledge of state and federal healthcare and health operations regulations.
- Strong organizational skills with the ability to meet deadlines and manage multiple priorities.
- Excellent verbal and written communication skills, including the ability to interface with staff across organizational lines, members, and providers.
- Proficiency in Microsoft Word, Access, and Excel.

Preferred Qualifications
- Experience in Appeals or Utilization Management.

Pay: ₹42.00 - ₹45.00 per hour

Work Location: Remote

📌 Quality Review Specialist (India)
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📍 India