Utilization Review Nurse

Job Title : Nurse Liaison | UM&QR

Location : Naperville IL | Hybrid

Duration : November 2025 to June 2026 (possible extension)

Pay : $41.00 / hr on W2

of Openings : 4

Position : Clinical Delegation Coordinator

BASIC FUNCTION : This position 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 BCBSIL's 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.

ESSENTIAL FUNCTIONS :

• 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.

JOB REQUIREMENTS :