Utilization Review Nurse New

Job Title: Nurse Liaison | UM&QR

Location: Naperville IL | Hybrid

Duration: November 2025 to June 2026 (possible extension)

Pay: $41.00/hr on W2

#of Openings: 4

Position: Clinical Delegation Coordinator

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 of BCBSIL’s 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.

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.