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Clinical Quality Review Specialist, RN
Health Care Service Corporation. Facilitate member and provider appeals .
Posted 10/7/2026full-timeRemote • Texas • United StatesMid-LevelSenior💰 $69,800 - $125,900 per yearWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in managing member and provider appeals while ensuring compliance with accreditation and regulatory requirements. Proficient in healthcare processes, particularly in managed care, with strong organizational and communication skills.
Highest-signal resume keywords
Registered Nurse (RN) LicenseHealthcare Processes KnowledgeManaged Care ProcessesUtilization Management ExperienceNCQA and URAC Standards Familiarity
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Healthcare ProcessesManaged Care ProcessesUtilization ManagementHealth Claims ExperienceRegulatory ComplianceAccreditation Standards KnowledgeInventory ManagementWorkflow Management
Soft Skills
Organizational SkillsVerbal CommunicationWritten CommunicationInterpersonal Skills
Tools & Technologies
Microsoft WordMicrosoft AccessMicrosoft ExcelMainframe Systems
Certifications & Qualifications
Registered Nurse (RN) License
Industry Keywords
Accreditation StandardsNCQAURACState and Federal RegulationsCustomer Relations
About the role
Key responsibilities & impact- Facilitate member and provider appeals
- Work closely with Medical Directors and Customer Service
- Ensure the appeal process meets established guidelines
- Adhere to accreditation and regulatory requirements to meet audit standards
- Manage individual inventory through appropriate workflow
Requirements
What you’ll need- Registered Nurse (RN) with unrestricted license in state of operations
- 5 years combined 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, including interfacing with staff across organizational lines, members, and providers
- PC experience including Microsoft Word, Access, and Excel
- Utilization management experience preferred
- Health claims and mainframe system experience preferred
- Experience with internal/external customer relations preferred
- Knowledge and familiarity of national accreditation standards, specifically NCQA and URAC standards preferred
- Knowledge of state and federal health care and health operations regulations preferred
- Work authorization without sponsorship; sponsorship is not available
- Ability to work 9 AM to 5:30 PM CST Monday through Friday, with occasional late shift coverage and rotating weekends/holidays
Benefits
Comp & perks- Curated development plans and professional development opportunities
- 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
- Annual incentive bonus plan
- Other incentives