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Nurse Liaison - UM & QR

Health Care | Chicago, IL | Full Time

Job Description
InGenesis, Inc. is seeking a highly qualified Utilization and Quality Review Nurse Liaison to work at our client site in Chicago, IL.  Hours are Monday – Friday, 40 hours per week.


QUALIFICATIONS
  • Registered Nurse (RN) with valid, current, unrestricted IL license.
  • 3 years clinical experience with 2 years’ experience in utilization review and case management.
  • 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. 


DUTIES
  • Review and evaluate UM/QR plans for prospective and existing Medical Groups/IPAs in the
  • HMO networks.
  • 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.
  • Evaluate results, prepare reports on findings, and communicates outcomes to Medical Groups/IPAs and HMO management.
  • 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, additional on-site visits, 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.
  • Travel to medical groups and IPAs for audits and in-services.
  • Prepare cost analyses and make 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.
  • 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 BCBSI 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.
  • Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.


ABOUT US
Established in 1998, InGenesis enjoys a long history of positive government and commercial relationships with healthcare industry professionals and businesses nationwide. We are the recent recipients of an Inc. 5000 award and dedicated to servicing our customers.

InGenesis is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin.