We are a leading healthcare organization committed to ensuring quality and timely care for our clients. Join our team of dedicated nurses who work autonomously to break down barriers and uphold the highest standards of healthcare.
What You'll Be Doing
Perform utilization review services in accordance with federal and state regulations and URAC standards for client members seeking healthcare treatment.
Gather, analyze, and document clinical data within the record.
Conduct timely reviews of healthcare services using appropriate medical criteria to make clinical determinations.
Communicate pre-certifications and review determinations to relevant parties as required by regulations and company policies.
Collaborate with Medical Directors and Peer Reviewers on cases requiring medical necessity review or quality of care assessments.
Interface regularly with ordering providers and provider organizations, occasionally engaging with members or their representatives.
Facilitate referrals of targeted patients to disease management programs to enhance continuity and quality of care.
Manage after-hours phone calls from members and providers on a rotational basis, ensuring confidentiality of information.
Participate in quality management activities and assist with clinical and client-specific reports.
Stay updated on regulatory requirements and integrate medical group guidelines and URAC standards into daily operations.
Maintain professional growth and education in line with Illinois Nurse Practice Act.
What You'll Need To Have
Registered Nurse with an active and unrestricted license.
Five years of experience across various healthcare settings.
Proficiency in utilization review, managed care, and community health.
Strong computer skills including MS Word, Excel, and Access.
Excellent organizational, writing, and verbal communication skills.
Ability to prioritize tasks in response to evolving business needs.
Demonstrated clinical judgment, compassion, and a positive demeanor.
Preferred Qualifications
Advanced degree or certification in Case Management, Utilization Review, and/or Quality.
Interest in Informatics.
Knowledge of Population Health and Disparities.
Compensation
Our comprehensive compensation package includes competitive base salary ranging from $70,000 to $75,000 annually, paid bi-weekly. Additionally, we offer world-class benefits such as medical, dental, and vision plans, long and short-term disability, life insurance, and a generous 401k plan with employer match. Our paid time off program includes holidays and flexible time to support work-life balance.
Equal Opportunity Employer
At our core, diversity, inclusion, and belonging shape our values. We are committed to equal opportunity employment, making decisions without regard to race, religion, color, age, sex, sexual orientation, national origin, citizenship, marital status, disability, veteran status, pregnancy, or any other legally protected status. We uphold this commitment in all aspects of employment.
Security And Compliance
This position adheres to all security policies and procedures to protect PHI under our custodianship and intellectual properties.
Employment Type: Full-Time
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Human Resources Services
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