Clinical Nurse Liaison

We're Hiring : Nurse Liaison!

We are seeking a dedicated and experienced Nurse Liaison to serve as a vital bridge between healthcare facilities, patients, and families. 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.

Location : Chicago, IL

Role : Nurse Liaison - Utilization Management and Quality Review

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.
• Oversees 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. Coordinates with Corporate Audit department regarding Corporate site audits and related corrective action plans. Performs follow-up reviews, additional on-site visits, and audits as needed.
• Designs and implements in-services, seminars, and special presentations which promote the UM / QR process in order to provide educational support to Medical Groups / IPAs. Travels to medical groups and IPAs for audits and in-services.
• Prepares cost analyses and makes 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.
• Provides necessary administrative support to assist Medical Groups / IPAs with unusual benefit requests, transplant cases, benefit terminations, IBMP cases, and other special issues. Coordinates activities of support staff.
• Assists management with the annual review and revision of UM / QR standards and audit tools to ensure compliance with NCQA and BCBSI HMO requirements.
• Works in close partnership with Network Consultants to develop strategies which will improve overall Medical Group / IPA performance and promote positive outcomes. Coordinates the transition of care for new and existing members who are currently undergoing a course of evaluation or medical treatment.
• Communicates trends and overall program performance to management.
• Participates 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.

JOB REQUIREMENTS :

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