Senior Review Coordinator - RN Utilization Management

Telligen
United States, Illinois, Chicago
Nov 17, 2024
The Senior Review Coordinator 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. Employees local to the Des Moines area will report to the West Des Moines office on monthly scheduled in-office days. Essential Functions Performs prospective, concurrent, or retrospective utilization review/medical management for all services including appropriateness of quality of care based on contract, state, or URAC requirements. Screens individual situations according to specific criteria to determine if care is appropriate. Refers cases that fail to meet screening criteria to peer reviewers. Coordinates and participates in peer-to-peer reviews as warranted. With prior management approval, may deviate from criteria with proper justification to authorize the service. Serves as liaison between peer reviewer, provider, facility, and/or subscriber. Coordinates and participates in the appeal process as directed by management. Trains or serves 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. Requirements Current and unrestricted RN License. Graduation from a nationally accredited nursing program. Must have multi-state/compact privileges and have the ability and willingness to obtain licensure in non-compact states as needed. 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 of recent experience working in a clinical environment. Because of the nature and immediacy of the work, the ability to maintain regular and predictable attendance is essential. COMMITMENT TO SAFETY As part of our commitment to health and safety, some roles may require additional health protocols (i.e. personal protective equipment or vaccination) Who We Are: Telligen is one of the most respected population health management organizations in the country. We work with state and federal government programs, as well as employers and health plans offering clinical, analytical, and technical expertise. Health has changed a lot through our 50-year history, but what has remained constant is that we care deeply about who we serve and what we do. Our success is built on our ability to adapt, respond to client needs, and offer innovative solutions. Our business is our people and we're looking for talented individuals who not only believe in our mission but who are ready to take ownership and make a difference in the lives of people, in the world of health. Learn more about who we are and what we do at www.telligen.com/about-us Are you Ready? We're on a mission to transform lives and economies by improving health and getting there means following through on our values of Ownership, Community, Ingenuity & Integrity. Ownership: As a 100% employee-owned company, our employee-owners drive our business, our solutions, and share in our success. When employee-owners grow and thrive, we all win. Community: Putting others first and being a good corporate partner wherever we work, and play makes us who we are. We Show Up. For our clients, for our communities, and for each other. Ingenuity: We're a team of passionate professionals driven by hard work and big ideas. We understand that high-value breakthroughs come from taking calculated risks. If it will benefit our clients and advance our mission, we're all ears. We celebrate free-thinking and challenge the status quo, so brainstorm away! Integrity: Smiling faces (virtual or in-person) are the norm around here. We enjoy a friendly work environment where everyone is dedicated to mutual trust, respect, and excellence. Thank you for your interest in Telligen! Follow us on Twitter, Facebook, and LinkedIn to learn more about our mission-driven culture and stay up to speed. Telligen and our affiliates are Affirmative Action, Equal Opportunity Employers (EOE/M/F/Vet/Disability), and E-Verify Participants. Telligen will not provide sponsorship for this position. If you will require sponsorship for work authorization now or in the future, we cannot consider your application at this time. Telligen does not accept 3rd party solicitations from outside staffing firms.