Nurse Liaison I - Utilization Management & Quality Review - Remote

Health Care Service Corp.; United States; Remoto; USD 70.000 - 126.000; Tempo pieno

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Health Care Service Corporation in the United States seeks a Registered Nurse for Utilization Management and Quality Review oversight. The role requires 5+ years of nursing experience with UR/QR exposure and travel as needed. This is a remote, nationwide position with potential for professional development.

The successful candidate will support clinical review activities, ensure compliance, and contribute to decisions affecting benefits and patient care across the health plan.

Competenze

• Registered Nurse (RN) with an unrestricted license.
• 3 years clinical experience with 2 years in utilization review, quality assurance, or statistical research.
• Clinical knowledge, UM/QR process, and managed care principles.
• Analytical, verbal, and written communications skills.
• Current Illinois driver’s license.
• Able and willing to travel, including overnight stays.

Mansioni

• Assist with benefit determinations and medical necessity reviews, ensuring sound, well-documented coverage decisions and compliance.

Conoscenze

RN license

Clinical experience

UM/QR knowledge

Analytical skills

Driver's license

Travel willingness

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About HCSC

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development.

For more than 80 years, HCSC has been dedicated to expanding access to high-quality, cost-effective health care and equipping our members with information and tools to make the best health care decisions for themselves and their families. As an industry leader, HCSC also has been helping to make the health care system work better for all Americans. To remain a leader, we offer compelling careers that encourage resourcefulness, strategic thought and empower you to make a difference in the lives of our members and their communities. Today, with the industry at an important crossroad, HCSC is reimagining health care and looking for original thinkers who aren’t afraid to make innovative contributions. We are an Equal Opportunity Employment employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Learn more about HCSC, our commitment to our members and the opportunity you’ll have to improve health care delivery in an open, collaborative environment.

Job Summary

This position is responsible for ensuring compliance with Utilization Management (UM) and Quality Review (QR) functions performed by the health plan. The role supports clinical review activities requiring 5+ years of experience as a Nurse Reviewer or Clinical Reviewer.

Responsibilities

• Assist with benefit determinations, medical necessity reviews, benefit terminations, and process improvements while ensuring clinically sound and well-documented coverage decisions and compliance.

Required Job Qualifications

• Registered Nurse (RN) with an 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.

Preferred Job Requirements

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

Sponsorship is not available

This is a remote role

Pay Transparency Statement

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees.

Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience.

This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

This position may be performed remotely from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii.

HCSC Employment Statement

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

We are a drug-free and smoke-free workplace.

Employment may be contingent upon successful completion of drug screening in accordance with applicable law.

Base Pay Range

$69,800.00 - $125,900.00 Exact compensation may vary based on skills, experience, and location.

If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at 1-866-977-7378 to request reasonable accommodations. Please note that only requests for accommodations in the application process will be returned.