Senior Review Coordinator - Utilization Management (RN)

Utilization Review/Medical Management Position

This position will be responsible for conducting utilization review/medical management for all services including training/mentoring other team members and performing preliminary research on requested topics. In addition, the incumbent may provide technical assistance, medical record review and support to provider staff and physician reviewers.

What you'll do:

• Perform prospective, concurrent or retrospective utilization review/medical management for all services including appropriateness of quality of care based on contract, state, or URAC requirements.
• Screen individual situations according to specific criteria to determine if care is appropriate.
• Refer cases that fail to meet screening criteria to peer reviewer.
• Coordinate and participate in peer-to-peer review as warranted. With prior management approval, may deviate from criteria with proper justification to authorize the service.
• Serve as liaison between peer reviewer, provider, facility and/or subscriber.
• Coordinate and participates in appeal process as directed by management.
• Train or serve as a mentor to team members and physician reviewers to ensure reviews and appeals are conducted thoroughly and within specified time frames.
• Performs preliminary research on topics such as experimental or cosmetic services, coverage determinations, coding or standards of care.
• Documents review and special project results in workflow documentation system, ensuring data is accurate and timely.
• Assists in compliance reporting.
• Performs miscellaneous duties as assigned.

Required Skills and Experience

• Current RN license that is recognized in the relevant jurisdiction(s) or other certification directly relevant to the type of review performed; Ability to obtain required license(s) in state(s) by timeframe set by business not to exceed 6 months
• Current RN license must be unrestricted and if there is a restriction that is allowed by a relevant jurisdiction, according to the Medical Director, it is of the type that does not affect the health professional's ability to fulfill the roles and responsibilities of a reviewer
• Four-year degree in health care or two- or three-year degree in nursing or related field and/or equivalent training and/or experience
• 3 5 years recent experience working in a clinical environment
• 5% local and/or overnight travel

Preferred Skills and Experience

• Knowledge of URAC standards
• Oncology experience highly preferred

Who We Are:

Telligen is one of the most respected population health management organizations in the country. We offer clinical, analytical, and technical expertise to support local, Tribal, and national partners, state and federal government programs, and employers and health plans.

Over our 50-year history, health care has evolved - and so have we. What hasn't changed is our deep commitment to those we serve. Our success is built on our ability to adapt, respond to client needs and deliver innovative, mission-driven solutions.

Our business is our people and we're seeking talented individuals who share our passion and are ready to take ownership, make an impact and help shape the future of health.

Are you Ready?

We're on a mission to transform lives and economies by improving health.

Ownership: As a 100% employee-owned company, our employee-owners drive our business and share in our success.

Community: We show up - for our clients, our communities and each other. Being a responsible corporate partner is part of who we are.

Ingenuity: We value bold ideas and calculated risks. Innovation thrives when we challenge the status quo and listen to diverse perspectives.

Integrity: We foster a respectful, inclusive, and collaborative environment built on trust and excellence.

Thank you for your interest in Telligen!

Telligen and our affiliates are Equal Opportunity Employers and E-Verify Participants.

Telligen is an equal opportunity employer. Qualified applicants will be considered without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, protected veteran status, disability or any other protected class.

Telligen is committed to ensuring that our employment process is open to all individuals, and provides reasonable accommodations to individuals who need assistance during any part of the employment process due to a disability, medical condition, or physical or mental impairment. Reasonable accommodations are considered on a case-by-case basis.

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