[Hiring] Nurse Liaison I @Health Care Service Corporation

Role Description

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 include:

• Assisting with benefit determinations
• Conducting medical necessity reviews
• Managing benefit terminations
• Implementing process improvements
• Ensuring clinically sound and well-documented coverage decisions and compliance

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

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

Benefits

• 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
• Other incentives

Company Description

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