Utilization Review Nurse (LPN)

w3r Consulting is an award-winning, best-in-class IT consulting and management company that delivers enterprise solutions at the intersection of innovation and ingenuity. Organizations throughout the healthcare payor, financial services, and professionals and business services sectors turn to w3r for a strategic, IT-fueled advantage that elevates their stature and capabilities in competitive global markets. As a minority-owned business, w3r brings diverse and multifaceted people from across different backgrounds and life experiences to the table, unlocking the power of unique perspectives and inventive ideas to help clients achieve their evolving goals.

Job Title: Quality Review Specialist Location: Downers Grove, IL (Remote but looking candidates in Illinois, Texas, Oklahoma, New Mexico & Montana) Contract: 6 Months Schedule: M-F (8 am to 5pm) Position Summary: The Appeals Specialist works with the Full-Service Unit (FSU), Provider Telecommunication Center (PTC), and Medical Management Department (MMD) to ensure appeal processes follow established guidelines and regulatory standards. This role manages appeal cases, resolves member and provider appeals promptly, and supports audits and compliance initiatives.

Collaborate with FSU, PTC, and MMD to ensure appeal guidelines and standards are met. Manage and resolve member and provider appeals efficiently. Ensure compliance with NCQA, URAC, DOI, and federal guidelines. Support audits, data reporting, and process improvements. Maintain strong communication with members, providers, and internal teams. Uphold confidentiality and comply with HIPAA and company policies.