Utilization Nurse in Warrenville, IL

Clinical Delegation Coordinator Location: Naperville, IL (Onsite for training; Fully Remote thereafter) Duration: 6-Month Assignment (Potential for extension) Role Overview As a Clinical Delegation Coordinator, you will act as the vital link between the health plan and provider groups. Your mission is to ensure that medical groups and IPAs within the HMO network maintain the highest standards of care. You will oversee Utilization Management (UM) and Quality Review (QR) processes, ensuring full compliance with regulatory standards while supporting complex medical cases. Key Responsibilities • Audit & Oversight: Review UM/QR programs for Medical Groups and IPAs to ensure alignment with NCQA and internal standards. • Compliance & Improvement: Lead corrective action plans when provider groups fall out of compliance and bridge gaps in performance. • Education: Empower provider staff through targeted trainings, in-services, and site visits. • Case Support: Partner with Medical Directors to navigate complex benefit cases, including transplants and extra-contractual benefits. • Data Analysis: Analyze utilization and audit data to communicate clear, actionable findings to leadership and providers. • Collaboration: Work alongside network and quality teams to drive better clinical outcomes across the board. What You'll Need to Succeed • Licensure: An active Illinois Registered Nurse (RN) license. • Experience: At least 3 years of clinical experience, complemented by 2 years in utilization review, quality assurance, or statistical research. • Knowledge Base: Deep understanding of UM/QR processes, managed care principles, and clinical standards. • Skills: Strong analytical capabilities paired with excellent verbal and written communication skills.