Utilization Review Nurse/ Appeals RN

Job Title: Quality Review Specialist

Location: Chicago, IL

Contract duration: 7 months

Schedule: 8am to 5pm (M-F)

Key Responsibilities:

• Manage and resolve member and provider appeals.
• Ensure compliance with NCQA, URAC, DOI, and regulatory guidelines.
• Collaborate with Medical Management, FSU, and PTC teams.
• Support audits, reporting, and quality initiatives.
• Communicate directly with members, providers, and internal teams.

Requirements:

• Registered Nurse (RN) with Bachelor’s degree.
• 5 years of experience in utilization management, appeals, or claims.
• Strong knowledge of managed care and accreditation standards (NCQA/URAC).
• Excellent communication, organizational, and MS Office skills.

Preferred:

• RN with Appeals and/or Utilization Management experience.