Nurse Liaison I - Utilization Management & Quality Review - Remote

Health Care Service Corporation•National, NV

1d•$69,800 - $125,900•Remote

About The Position

This position ensures compliance with Utilization Management (UM) and Quality Review (QR) functions performed by the health plan and supports clinical review activities. The role assists with benefit determinations, medical necessity reviews, benefit terminations, and process improvements, while ensuring coverage decisions are clinically sound, well documented, and compliant. The job summary describes clinical review activities requiring 5+ years of experience as a Nurse Reviewer or Clinical Reviewer.

Requirements

Registered Nurse (RN) with an unrestricted license.
Three years of clinical experience, including two years of experience in utilization review, quality assurance, or statistical research.
Clinical knowledge and knowledge of the UM/QR process and managed care principles.
Analytical, verbal, and written communication skills.
Current Illinois driver’s license.
Able and willing to travel, including overnight stays.

Nice To Haves

Five or more years of Medicare Review and Medicare Advantage Health Plan experience.
Four or more years of experience as a Nurse Reviewer, Clinical Reviewer, or in a similar clinical review role.
Strong prior authorization experience within a Medicare Advantage or managed care environment.
Exceptional clinical knowledge and a strong understanding of health plan operations and utilization management processes.
Extensive clinical decision-making experience, including independently evaluating medical necessity and coverage determinations.
Experience serving as the final clinical reviewer before denial determination and ensuring decisions are clinically sound and supported by documentation.
Demonstrated experience developing clear, comprehensive clinical write-ups to support authorization and denial decisions.

Responsibilities

Ensure compliance with the health plan’s Utilization Management and Quality Review functions.
Support clinical review activities.
Assist with benefit determinations, medical necessity reviews, and benefit terminations.
Contribute to process improvements.
Ensure coverage decisions are clinically sound, well documented, and compliant.