Nurse Liaison I - Utilization Management & Quality Review
New
H
HCSCHealth insurance
This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and HawaiiFull-TimeEntry
SalaryBase Pay Range $69,800.00 - $125,900.00
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Job Details
- Experience
- 3 years clinical experience with 2 years’ experience in utilization review, quality assurance, or statistical research. Preferred: 5+ years of Medicare Review and Medicare Advantage Health Plan experience; 4+ years of experience as a Nurse Reviewer, Clinical Reviewer, or similar clinical review role.
- Required Skills
- Quality Assurance
Requirements
- Hold an unrestricted Registered Nurse (RN) license.
- Have 3 years of clinical experience.
- Have 2 years of experience in utilization review, quality assurance, or statistical research.
- Bring clinical knowledge and knowledge of the Utilization Management and Quality Review process.
- Bring knowledge of managed care principles.
- Hold a current Illinois driver’s license.
- Be able and willing to travel, including overnight stays.
- Preferred: 5+ years of Medicare Review and Medicare Advantage Health Plan experience.
- Preferred: 4+ years as a Nurse Reviewer, Clinical Reviewer, or in a similar clinical review role.
- Preferred: Strong prior authorization experience in a Medicare Advantage or managed care environment.
- Preferred: Experience independently evaluating medical necessity and coverage determinations.
- Preferred: Experience as the final clinical reviewer before denial determination and developing clinical write-ups supporting authorization and denial decisions.
Responsibilities
- Support clinical review activities for Utilization Management and Quality Review functions performed by the health plan.
- Assist with benefit determinations and medical necessity reviews.
- Assist with benefit terminations.
- Help improve processes while ensuring compliance.
- Ensure coverage decisions are clinically sound and well documented.
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