EPITEC · 8 hours ago
Quality Review Specialist
Chicago, IL
Contract
Onsite
Senior Level
$42/hr - $42/hr
5+ years expEPITEC is a company that supports the end-to-end appeals process for healthcare services. The Quality Review Specialist role involves ensuring compliance and timely resolution of member and provider appeals while collaborating across various operational teams.
Information TechnologyStaffing Agency
Responsibilities
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 workgroups 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
Qualification
Required
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
Preferred
Appeals and/or utilization management experience
Company
EPITEC
Epitec is a premier technology services and professional staffing company.
1001-5000 employees
H1B Sponsorship
EPITEC has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (189)
2024 (148)
2023 (154)
2022 (266)
2021 (203)
2020 (172)
Funding
Current Stage
Late StageLeadership Team
Mark Ruma
Chief Operating Officer (COO)
Company data provided by crunchbase