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Clinical Utilization Review Specialist

1 month ago


Chicago, Illinois, United States Integrated Resources, Inc Full time
Job Summary

This Clinical Utilization Review Specialist role is a vital part of our team at Integrated Resources, Inc.

About the Role

We 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
  1. 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.
  2. 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.
  3. 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.
Requirements
  • 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
About Us

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.