Healthcare Compliance Specialist

5 days ago


Chicago, Illinois, United States Integrated Resources, Inc Full time
About the Role

We are seeking a skilled Healthcare Compliance Specialist to join our team at Integrated Resources, Inc. In this role, you will be responsible for ensuring compliance with Utilization Management (UM) and Quality Review (QR) functions performed by medical groups/IPAs participating in our networks.

Key Responsibilities
  • Evaluate UM/QR plans for prospective and existing medical groups/IPAs in our HMO networks, preparing reports on findings and communicating outcomes to medical groups/IPAs and HMO management.
  • Communicate 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.
  • Monitor UM activities of medical groups/IPAs to measure adherence to HMO UM/QR standards by conducting annual UM/QR audits, evaluating results, preparing reports on findings, and communicating outcomes to medical groups/IPAs and HMO management.
Requirements

To be successful in this role, you will need:

  • A Registered Nurse (RN) with an unrestricted license.
  • At least 3 years of clinical experience, with 2 years of 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 communication skills.
  • A current Illinois driver's license.
  • The ability and willingness to travel, including overnight stays.
Compensation

The estimated salary for this role is $80,000 - $110,000 per year, depending on experience.



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