Utilization Management Specialist
6 days ago
The Utilization Management Specialist is a critical role at w3r Consulting, responsible for ensuring compliance with Utilization Management (UM) and Quality Review (QR) functions performed by Medical Groups/IPAs participating in our networks. This position requires a Registered Nurse (RN) with 3 years of clinical experience, including 2 years in utilization review, quality assurance, or statistical research.
Responsibilities- Evaluate UM/QR plans for prospective and existing Medical Groups/IPAs, preparing reports on findings and communicating outcomes to stakeholders.
- Communicate contractual requirements to medical groups, IPAs, and contract management firms, as well as corporate headquarters.
- Monitor UM activities of Medical Groups/IPAs, conducting annual UM/QR audits and evaluating results.
- Oversee the development and implementation of corrective action plans for deficient Medical Groups/IPAs.
- Design and implement educational seminars and in-services promoting the UM/QR process.
- Prepare cost analyses and make recommendations on extra contractual benefit requests.
- Provide administrative support for unusual benefit requests, transplant cases, and other special issues.
- 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.
$85,000 - $105,000 per year, depending on experience.
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