Epitec
POSITION:
Registered Nurse
JOB TYPE:
Full-time, Contract, W2
LOCATION:
Chicago, IL
JOB SUMMARY FOR REGISTERED NURSE:
- 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 HMO networks. The role involves evaluating, designing, and implementing educational seminars for Medical Groups/IPA staff, assisting in benefit determinations, and providing support on transplant requests, benefit terminations, and Individual Benefit Management Program (IBMP) cases.
RESPONSIBILITIES FOR REGISTERED NURSE:
- Review and Evaluation: Assess UM/QR plans for prospective and existing Medical Groups/IPAs in the HMO networks. Prepare and communicate reports on findings.
- Contractual Communication: Relay contractual requirements to medical groups, IPAs, contract management firms, and corporate headquarters.
- Monitoring and Auditing: Conduct annual UM/QR audits to measure adherence to HMO UM/QR standards. Prepare and communicate audit reports.
- Corrective Action Plans: Develop and implement corrective action plans for non-compliant Medical Groups/IPAs. Coordinate with Corporate Audit department and perform follow-up reviews.
- Educational Support: Design and implement in-services, seminars, and special presentations to promote the UM/QR process. Travel to medical groups and IPAs for audits and in-services.
- Cost Analysis and Recommendations: Prepare cost analyses and make recommendations on extra contractual benefit requests. Monitor usage of approved benefits.
- Administrative Support: Assist Medical Groups/IPAs with unusual benefit requests, transplant cases, benefit terminations, IBMP cases, and other special issues. Coordinate support staff activities.
- Standards and Tools Review: Assist in the annual review and revision of UM/QR standards and audit tools to ensure compliance with NCQA and HMO requirements.
- Strategy Development: Work with Network Consultants to develop strategies to improve Medical Group/IPA performance and promote positive outcomes. Coordinate care transitions for members.
- Program Performance Communication: Communicate trends and overall program performance to management.
- Committee Participation: Participate in various related committees as necessary.
- Professional Communication: Communicate and interact effectively and professionally with co-workers, management, and customers.
- Compliance: Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies, and other applicable corporate and departmental policies.
- Confidentiality: Maintain complete confidentiality of company business.
- Special Projects: Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.
REQUIRED EXPERIENCE FOR REGISTERED NURSE:
- Registered Nurse (RN) with an unrestricted license.
- Experience: 3 years of clinical experience with 2 years in utilization review, quality assurance, or statistical research.
SKILLS AND QUALIFICATIONS FOR REGISTERED NURSE:
- Knowledge: Clinical knowledge, UM/QR process, and managed care principles.
- Skills: Analytical, verbal, and written communication skills.
- Other Requirements: Current Illinois driver’s license. Ability and willingness to travel, including overnight stays.