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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
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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
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.
Additional Information
Company: HCSC
Location: Anywhere
Salary: $69,800.00 - $125,900.00 per year
Job ID: R0056005
Specialties: Managed Care, Clinical Review Nurse, Medicare, Utilization Management, Prior Authorization
Required Licenses: RN
Experience Level: 5-10 years
