Nurse Liaison I – Utilization Management, Quality Review
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Posted: 10/20/2026Nurse Liaison I – Utilization Management, Quality Review
Health Care Service CorporationPosted 10/20/2026full-timeRemote • Illinois • United StatesMid-LevelSenior💰 $69,800 - $125,900 per yearWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive clinical knowledge and experience in Utilization Management and Quality Review processes, with a strong ability to conduct medical necessity reviews and develop comprehensive clinical documentation. Proven analytical and communication skills are essential for effective collaboration and decision-making in a managed care environment.
Highest-signal resume keywords
Registered Nurse (RN) LicenseUtilization Review ExperienceClinical Decision-MakingMedicare Advantage ExperienceClinical Review Documentation
About the role
Key responsibilities & impact- Ensure compliance with Utilization Management (UM) and Quality Review (QR) functions performed by the health plan
- Support clinical review activities
- Assist with benefit determinations
- Conduct medical necessity reviews
- Handle benefit terminations
- Contribute to process improvements
- Ensure clinically sound and well-documented coverage decisions and compliance
Requirements
What you’ll need- 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
- Sponsorship is not available
- Preferred: 5+ years of Medicare Review and Medicare Advantage Health Plan experience
- Preferred: 4+ years of experience as a Nurse Reviewer, Clinical Reviewer, or similar clinical review role
- Preferred: Strong prior authorization experience within a Medicare Advantage or managed care environment
- Preferred: Exceptional clinical knowledge combined with a strong understanding of health plan operations and utilization management processes
- Preferred: Extensive clinical decision-making experience with the ability to independently evaluate medical necessity and coverage determinations
- Preferred: Experience serving as the final clinical reviewer prior to denial determination
- Preferred: Demonstrated experience developing clear, comprehensive clinical write-ups to support authorization and denial decisions
Benefits
Comp & perks- Curated development plans and professional development opportunities
- Annual incentive bonus plan
- 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
- Remote work from anywhere within the continental United States, excluding California, New York, Alaska, and Hawaii
ATS Keywords
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Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewMedical Necessity ReviewBenefit DeterminationQuality AssuranceProcess ImprovementStatistical ResearchPrior AuthorizationManaged Care PrinciplesCoverage DeterminationsClinical Knowledge
Soft Skills
Analytical SkillsVerbal CommunicationWritten Communication
Certifications & Qualifications
Registered Nurse (RN) License
Industry Keywords
Utilization Management (UM)Quality Review (QR)Medicare ReviewHealth Plan OperationsManaged Care