UTILIZATION MANAGEMENT - QUALITY REVIEW - HMO -NURSE
Company: HireOps Staffing LLC
Location: Chicago
Posted on: October 9, 2024
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Job Description:
This position is a contract to hire. This position is onsite,
downtown Chicago.
BASIC FUNCTION: This position is responsible for ensuring
compliance of the Utilization Management (UM) and Quality Review
(QR) functions performed by the Medical Groups/IPAs participating
in the networks - HMOs. Evaluates the need for, designs, and
implements educational seminars for Medical Groups/IPA staff,
assists in benefit determinations, and provides support on
transplant requests, benefit terminations and Individual Benefit
Management Program (IBMP) cases. ESSENTIAL FUNCTIONS:1. Reviews and
evaluates UM/QR plans for prospective and existing Medical
Groups/IPAs in the HMO networks. Prepares reports on findings and
communicates outcomes to Medical Groups/IPAs and HMO management.2.
Communicates 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.3. Monitors UM activities of
Medical Groups/IPAs to measure adherence to HMO UM/QR standards by
conducting annual UM/QR audits. Evaluates results, prepares reports
on findings, and communicates outcomes to Medical Groups/IPAs and
HMO management.4. Oversees the development and implementation of
corrective action plans for deficient Medical Groups/IPAs as a
result of Utilization Management statistics, non-compliance with UM
policies and procedures, UM/QR plan reviews, and UM/QR audits.
Coordinates with Corporate Audit department regarding Corporate
site audits and related corrective action plans. Performs follow-up
reviews, additional on-site visits, and audits as needed.5. Designs
and implements in-services, seminars, and special presentations
which promote the UM/QR process in order to provide educational
support to Medical Groups/IPAs. Travels to medical groups and IPAs
for audits and in-services.6. Prepares cost analyses and makes
recommendations to the Medical Director(s) on extra contractual
benefit requests. Communicates decision to Medical Group/IPA and
monitors usage of approved extra contractual benefits.7. Provides
necessary administrative support to assist Medical Groups/IPAs with
unusual benefit requests, transplant cases, benefit terminations,
IBMP cases, and other special issues. Coordinates activities of
support staff.8. Assists management with the annual review and
revision of UM/QR standards and audit tools to ensure compliance
with NCQA and BCBSI HMO requirements.9. Works in close partnership
with Network Consultants to develop strategies which will improve
overall Medical Group/IPA performance and promote positive
outcomes. Coordinates the transition of care for new and existing
members who are currently undergoing a course of evaluation or
medical treatment.10. Communicates trends and overall program
performance to management.11. Participates on various related
committees as necessary.12. Communicate and interact effectively
and professionally with co-workers, management, customers, etc.13.
Comply with HIPAA, Diversity Principles, Corporate Integrity,
Compliance Program policies and other applicable corporate and
departmental policies.14. Maintain complete confidentiality of
company business.15. Maintain communication with management
regarding development within areas of assigned responsibilities and
perform special projects as required or requested. JOB
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. Able and willing to
travel, including overnight stays.
Keywords: HireOps Staffing LLC, Wheaton , UTILIZATION MANAGEMENT - QUALITY REVIEW - HMO -NURSE, Executive , Chicago, Illinois
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