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Clinical Utilization Review Specialist
1 month ago
This Clinical Utilization Review Specialist role is a vital part of our team at Integrated Resources, Inc.
About the RoleWe are seeking a highly skilled and experienced Registered Nurse to join our team as a Clinical Utilization Review Specialist. In this role, you will play a crucial part in ensuring compliance with utilization management (UM) and quality review (QR) functions performed by medical groups and independent practice associations participating in our networks.
Key Responsibilities- Compliance and Audits: You will be responsible for reviewing and evaluating 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.
- Communication and Education: You will communicate contractual requirements to medical groups, IPAs, and contract management firms, corporate headquarters, and provide educational support to medical groups/IPAs through in-services, seminars, and special presentations.
- Travel and Development: You will travel to medical groups and IPAs for audits and in-services, and participate in the development and implementation of corrective action plans for deficient medical groups/IPAs.
- 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 driver's license
- Able and willing to travel, including overnight stays
Integrated Resources, Inc. is a leading healthcare organization dedicated to providing high-quality services to our clients. We offer a competitive salary range of $85,000 - $110,000 per year, depending on experience.