Clinical Quality Review Specialist (RN) – Work From Home

Location: Remote within the continental United States; California, New York, Alaska, and Hawaii are excluded. Work hours are 9:00 AM–5:30 PM CST, Monday through Friday, with occasional late-shift coverage and rotating weekends and holidays.

Base pay: $69,800–$125,900 annually. An annual incentive bonus plan may also apply.

Company

hirify.global provides health insurance and managed care services.

What you will do

• Facilitate member and provider appeals.
• Coordinate with Medical Directors and Customer Service to ensure appeals follow established guidelines.
• Apply accreditation and regulatory requirements to support audit-ready processes.
• Manage an individual appeal inventory through appropriate workflows.
• Communicate with members, providers, and internal stakeholders across organizational functions.

Requirements

• Registered Nurse with an unrestricted license in the state of operations.
• Five years of combined healthcare process knowledge and experience.
• Knowledge of managed care processes.
• Strong organization, prioritization, deadline-management, verbal, and written communication skills.
• PC experience with Microsoft Word, Access, and Excel.
• Sponsorship is not available.

Nice to have

• Bachelor’s degree.
• Utilization management experience.
• Health claims and mainframe system experience.
• Experience with internal and external customer relations.
• Knowledge of NCQA and URAC accreditation standards and state and federal healthcare regulations.

Culture & Benefits

• Remote work-from-home arrangement within the permitted United States locations.
• Professional development plans and tuition reimbursement.
• Health and wellness benefits, including disability insurance, supplemental life insurance, and an employee assistance program.
• 401(k) savings plan, pension plan, paid time off, paid parental leave, and paid holidays.