Nurse Liaison I – Utilization Management, Quality Review

🔥 13 hours ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $69.8k - $125.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Health Care Service Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Health Care Service Corporation is an independent licensee of the Blue Cross Blue Shield Association, serving nearly 23 million people across the United States with a wide range of health benefit solutions. The company provides health coverage options for various groups, including employers, individuals, families, as well as Medicare and Medicaid plans. In addition to health insurance, HCSC offers services such as pharmacy solutions, life and dental insurance, and health data technology. With nearly a century of experience, HCSC is dedicated to improving access to quality care, enhancing health outcomes, and reducing costs while maintaining a deep commitment to its members and local communities.

📋 Description

• Ensure compliance with Utilization Management (UM) and Quality Review (QR) functions performed by the health plan • Support clinical review activities • Assist with benefit determinations • Conduct medical necessity reviews • Handle benefit terminations • Contribute to process improvements • Ensure clinically sound and well-documented coverage decisions and compliance

🎯 Requirements

• Registered Nurse (RN) with an 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 • Sponsorship is not available • Preferred: 5+ years of Medicare Review and Medicare Advantage Health Plan experience • Preferred: 4+ years of experience as a Nurse Reviewer, Clinical Reviewer, or similar clinical review role • Preferred: Strong prior authorization experience within a Medicare Advantage or managed care environment • Preferred: Exceptional clinical knowledge combined with a strong understanding of health plan operations and utilization management processes • Preferred: Extensive clinical decision-making experience with the ability to independently evaluate medical necessity and coverage determinations • Preferred: Experience serving as the final clinical reviewer prior to denial determination • Preferred: Demonstrated experience developing clear, comprehensive clinical write-ups to support authorization and denial decisions

🏖️ Benefits

• Curated development plans and professional development opportunities • Annual incentive bonus plan • Health and wellness benefits • 401(k) savings plan • Pension plan • Paid time off • Paid parental leave • Disability insurance • Supplemental life insurance • Employee assistance program • Paid holidays • Tuition reimbursement • Other incentives • Remote work from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii