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Nurse Liaison I

2 months ago

Chicago, United States Integrated Resources Full time
Job Title: Nurse Liaison I
Location: Naperville/Chicago IL onsite location
Duration: 6 months+ (possible Contract to Hire)

Schedule: Mon to Fri 40hrs/week

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 Client'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.
  • 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 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.12. Communicate and interact effectively and professionally with co-workers, management, customers, etc.13. 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.
Education:
  • Registered Nurse or Licensed Clinical Social Worker
Job Requirements:
  • Registered Nurse (RN) with unrestricted license.
  • 3 years clinical experience with 2 year's 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 driver's license. Able and willing to travel, including overnight stays.