Nurse Liaison I - Utilization Management & Quality Review - Remote

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 include assisting 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

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

Base Pay Range

$69,800.00 - $125,900.00