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.
Responsibilities:
• 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.
Requirements:
• 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.
Benefits:
Solving IT, a Woman and LGBTQ+ owned and operated organization is thrilled to provide a comprehensive benefit package to all our W2 employees and their families, regardless of gender.
We are proud to offer five diverse health plan options as well as a PPO dental plan through Blue Cross Blue Shield, Term Life/AD&D Insurance, and a 401(k) Savings Plan.
Solving IT covers a portion of the health and dental premiums for our employees.
As you progress in your professional journey, Solving IT is dedicated to accommodating your evolving preferences and matching you with fulfilling projects.
We champion equality and embrace diversity in all its forms.
Creating an atmosphere that encourages varied perspectives to collaborate fosters personal development, strengthens team unity, and contributes to the overall success of the organization!
Whether you're seeking your next career challenge or aiming to stay abreast of industry trends, Solving IT is committed to supporting your career advancement.
We actively encourage applications from all backgrounds and utilize the most up-to-date market insights and compensation data to ensure that you receive not just advice, but the complete Solving IT Experience.