Position: Nurse Liaison
Location: Naperville, IL (fully remote; on-site training required)
Employment Type: Full-Time Contract
Pay: $41 per hour
Description: This position is responsible for ensuring compliance of the Utilization Management (UM) and Quality Review (QR) functions performed by the Medical Groups/IPAs. You will be evaluating the need for, designing, and implementing educational seminars for Medical Groups/IPA staff, assisting in benefit determinations, and providing support on transplant requests, benefit terminations and Individual Benefit Management Program (IBMP) cases.
Responsibilities:
- Review and evaluate UM/QR plans for prospective and existing Medical Groups/IPAs in the HMO networks.
- Evaluate results and prepare reports on findings and communicate outcomes to Medical Groups/IPAs and HMO management
- Communicate 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
- Monitor UM activities of Medical Groups/IPAs to measure adherence to HMO UM/QR standards by conducting annual UM/QR audits
- Oversee 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
- Coordinate with Corporate Audit department regarding corporate site audits and related corrective action plans
- Perform follow-up reviews and audits as needed
- Design and implement in-services, seminars, and special presentations which promote the UM/QR process in order to provide educational support to Medical Groups/IPAs
- Prepare cost analyses and makes recommendations to the Medical Director(s) on extra contractual benefit requests
- Communicate decision to Medical Group/IPA and monitor usage of approved extra contractual benefits
- Provide necessary administrative support to assist Medical Groups/IPAs with unusual benefit requests, transplant cases, benefit terminations, IBMP cases, and other special issues
- Coordinate activities of support staff
- Assist management with the annual review and revision of UM/QR standards and audit tools to ensure compliance with NCQA and HMO requirements
- Work in close partnership with Network Consultants to develop strategies which will improve overall Medical Group/IPA performance and promote positive outcomes
- Coordinate the transition of care for new and existing members who are currently undergoing a course of evaluation or medical treatment
- Communicate trends and overall program performance to management
- Participate 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) or License Clinical Social Worker (LCSC) with an unrestricted license in the state of Illinois
- 3 years of clinical experience
- 2 years of 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
Preferred:
- UM experience
- NCQA Accreditation standards experience