Utilization Review Nurse (Naperville)

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 BCBSILs 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 :

1. 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.

2. 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.

3. 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 :

• ? 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 drivers license.
• ? Able and willing to travel, including overnight stays .