Nurse Liaison I UM & QR 27095
One of the largest health insurers in the nation is focused on continuously building an industry-defining, world-class IT capability. Healthcare is forever evolving, especially due to emerging technologies, making this a great experience to add to your resume. Come join their winning team!
This contract role as a Nurse Liaison I UM & QR in Chicago, IL is responsible for ensuring compliance of the Utilization Management (UM) and Quality Review (QR) functions performed by the Medical Groups/IPAs participating in the networks of HMOs. Evaluates the need for, designs, and implements educational seminars for Medical Groups/IPA staff, assists in benefit determinations, and provides support on transplant requests, benefit terminations and Individual Benefit Management Program (IBMP) cases. This role is remote until a return to work is established.
• Reviews and evaluates UM/QR plans for prospective and existing Medical Groups/IPAs in the HMO networks. Prepares reports on findings and communicates outcomes to Medical Groups/IPAs and HMO management.
• Communicates contractual requirements to medical groups, IPAs, and contract management firms, corporate headquarters including but not limited to utilization management, quality review, clinical, and non-clinical quality improvement.
• Monitors UM activities of Medical Groups/IPAs to measure adherence to HMO UM/QR standards by conducting annual UM/QR audits. Evaluates results, prepares reports on findings, and communicates outcomes to Medical Groups/IPAs and HMO management.
• Oversees the development and implementation of corrective action plans for deficient Medical Groups/IPAs as a result of Utilization Management statistics, non-compliance with UM policies and procedures, UM/QR plan reviews, and UM/QR audits. Coordinates with Corporate Audit department regarding Corporate site audits and related corrective action plans. Performs follow-up reviews, additional on-site visits, and audits as needed.
• Designs and implements in-services, seminars, and special presentations which promote the UM/QR process in order to provide educational support to Medical Groups/IPAs. Travels to medical groups and IPAs for audits and in-services.
• Prepares cost analyses and makes recommendations to the Medical Director(s) on extra contractual benefit requests. Communicates decision to Medical Group/IPA and monitors usage of approved extra contractual benefits.
• Provides necessary administrative support to assist Medical Groups/IPAs with unusual benefit requests, transplant cases, benefit terminations, IBMP cases, and other special issues. Coordinates activities of support staff.
• Assists management with the annual review and revision of UM/QR standards and audit tools to ensure compliance with NCQA and HMO requirements.
• Works in close partnership with Network Consultants to develop strategies which will improve overall Medical Group/IPA performance and promote positive outcomes. Coordinates the transition of care for new and existing members who are currently undergoing a course of evaluation or medical treatment.
• Communicates trends and overall program performance to management.
• Participates on various related committees as necessary.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
• Registered Nurse (RN) with unrestricted license.
• 3 years clinical experience with 2 years experience in utilization review, quality assurance, or statistical research.
• Clinical knowledge, knowledge of the UM/QR process, and knowledge of managed care principles.
• Analytical, verbal and written communications skills.
• Current Illinois driver’s license.
• Able and willing to travel, including overnight stays.
Solving IT is pleased to offer a rich benefit plan to our W2 employees. We offer five health plan options and a PPO dental plan through Blue Cross Blue Shield, Term Life/AD&D Insurance, and 401(k) Savings Plan. Solving IT subsidizes the health and dental premium for the employee.
As you continue to develop your skills and experience, Solving IT will work with your changing preferences to match you with rewarding projects. Our unrivaled reputation for quality is demonstrated through our Inavero Best of Staffing award that was won due to the feedback from our own clients and candidates. We also love to socialize and have fun so we have regularly scheduled parties and events for you to unwind and network with fellow consultants.
Whether you are searching for your next challenge or just looking to stay on top of market trends, Solving IT is committed to help position you appropriately. By leveraging the latest market and compensation data available, you can rest assured that you are getting more than just an informed opinion. You are getting the Solving IT Experience.