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Nurse Liaison I UM Specialist
2 months ago
At Solving IT, we are seeking a highly skilled and experienced Nurse Liaison I UM to join our team. As a key member of our Utilization Management and Quality Review department, you will play a critical role in ensuring the compliance of Utilization Management (UM) and Quality Review (QR) functions performed by Medical Groups/IPAs participating in our networks.
Responsibilities:- Reviews and evaluates UM/QR plans for prospective and existing Medical Groups/IPAs in our 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.
- 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.
- Coordinates with Corporate Audit department regarding Corporate site audits and related corrective action plans.
- 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.
- 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.
Solving IT is proud to offer a comprehensive benefit package to all our W2 employees and their families, regardless of gender. We provide five diverse health plan options, a PPO dental plan through Blue Cross Blue Shield, Term Life/AD&D Insurance, and a 401(k) Savings Plan. Solving IT covers a portion of the health and dental premiums for our employees.
We champion equality and embrace diversity in all its forms. Creating an atmosphere that encourages varied perspectives to collaborate fosters personal development, strengthens team unity, and contributes to the overall success of the organization.
We actively encourage applications from all backgrounds and utilize the most up-to-date market insights and compensation data to ensure that you receive not just advice, but the complete Solving IT Experience.