Utilization Management Specialist

6 days ago


Chicago, Illinois, United States w3r Consulting Full time
Job Description

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.
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.
Salary Range

$85,000 - $105,000 per year, depending on experience.



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