Utilization/Quality Review RN

w3r Consulting is an award-winning, best-in-class IT consulting and management company that delivers enterprise solutions at the intersection of innovation and ingenuity. Organizations throughout the healthcare payor, financial services, and professionals and business services sectors turn to w3r for a strategic, IT-fueled advantage that elevates their stature and capabilities in competitive global markets. As a minority-owned business, w3r brings diverse and multifaceted people from across different backgrounds and life experiences to the table, unlocking the power of unique perspectives and inventive ideas to help clients achieve their evolving goals.

Job Title: Nurse Liaison I UM & QR Location: Onsite in Naperville, IL for training, then fully remote Contract Duration: 8 Months Schedule: Monday to Friday | 8:00 AM – 5:00 PM Job Summary: The Utilization Management & Quality Review Nurse is responsible for ensuring compliance with Utilization Management (UM) and Quality Review (QR) functions across Medical Groups and Independent Practice Associations (IPAs) within HMO networks. This role involves conducting audits, developing corrective action plans, and providing education and support to improve care quality and compliance with HMO standards.

Review and evaluate UM/QR plans for Medical Groups/IPAs. Conduct UM/QR audits and prepare detailed reports on findings. Monitor compliance with UM policies and quality review standards. Develop and implement corrective action plans for non-compliance. Provide training and educational support to Medical Group/IPA staff. Assist with benefit determinations, transplant requests, and special cases. Collaborate with Network Consultants to enhance performance and care outcomes. Maintain compliance with NCQA, BCBSI, and other regulatory requirements.