Utilization Management & Quality Review Nurse (RN)

Job Description

Job Title : Nurse Liaison I UM & QR

Location : Onsite in Naperville, IL for training, then fully remote

Contract Duration : 8 Months

Schedule : Monday to Friday | 8 : 00 AM – 5 : 00 PM

Job Summary

The Utilization Management & Quality Review Nurse is responsible for ensuring compliance with Utilization Management (UM) and Quality Review (QR) functions across Medical Groups and Independent Practice Associations (IPAs) within HMO networks. This role involves conducting audits, developing corrective action plans, and providing education and support to improve care quality and compliance with HMO standards.

Key Responsibilities

• Review and evaluate UM / QR plans for Medical Groups / IPAs.
• Conduct UM / QR audits and prepare detailed reports on findings.
• Monitor compliance with UM policies and quality review standards.
• Develop and implement corrective action plans for non-compliance.
• Provide training and educational support to Medical Group / IPA staff.
• Assist with benefit determinations, transplant requests, and special cases.
• Collaborate with Network Consultants to enhance performance and care outcomes.
• Maintain compliance with NCQA, BCBSI, and other regulatory requirements.

Qualifications