Nurse Liaison I UM and QR

Apply now and our proprietary system will quickly have you in front of a live recruiter.

The Opportunity

Description

We're looking for a Utilization Management (UM) and Quality Review (QR) , working in Insurance industry in Chicago, Illinois, United States .

• 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.
• Communicates and interacts effectively and professionally with co-workers, management, customers, etc.
• Complies with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintains complete confidentiality of company business.
• Maintains communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

Our Client

Our client is a fast-growing industry-recognized staffing firm. Recruiting critical IT, Financial, Engineering, Healthcare, and Data Analytics talent. With 20 years' experience and growth.

Connections in Automotive, Healthcare, Retail, Financial & Insurance, and Professional & Business Services. Working to bring top talent together with premier organizations.

Big enough to have great opportunities. Small enough to care about finding the right one for you.

It'sabout relationships based on mutual interest. The results are low turnover, long-lasting partnerships and growth. Want to work for a company invested in your success?

Experience Required for Your Success

What Do You Think?

Does your experience reflect what it takes to be successful in this role? Do the work and challenges get you excited about what's possible?