Clinical Utilization Review Specialist
2 weeks ago
We are seeking a highly skilled and experienced Clinical Utilization Review Specialist to join our team at Innovative Systems Group. As a key member of our team, you will be responsible for ensuring compliance with utilization management and quality review functions performed by medical groups and IPAs participating in our networks.
Key Responsibilities- Review and evaluate utilization management and quality review plans for prospective and existing medical groups and IPAs in our networks.
- Communicate contractual requirements to medical groups, IPAs, and contract management firms, corporate headquarters, including but not limited to utilization management, quality review, clinical, and non-clinical quality improvement.
- Monitor utilization activities of medical groups and IPAs to measure adherence to our utilization management and quality review standards by conducting annual audits.
- Oversee the development and implementation of corrective action plans for deficient medical groups and IPAs as a result of utilization management statistics, non-compliance with utilization management policies and procedures, utilization management and quality review plan reviews, and utilization management and quality review audits.
- Design and implement in-services, seminars, and special presentations which promote the utilization management and quality review process in order to provide educational support to medical groups and IPAs.
- Prepare cost analyses and make recommendations to the Medical Director(s) on extra contractual benefit requests.
- Provide necessary administrative support to assist medical groups and IPAs with unusual benefit requests, transplant cases, benefit terminations, IBMP cases, and other special issues.
- Assist management with the annual review and revision of utilization management and quality review standards and audit tools to ensure compliance with NCQA and BCBSI HMO requirements.
- Work in close partnership with Network Consultants to develop strategies which will improve overall medical group and IPA performance and promote positive outcomes.
- 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 utilization management and quality review 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.
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