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Telligen · 3 weeks ago

Sr. Review Coordinator - Utilization Management (RN)

West Des Moines, IA

Full-time

Hybrid

Mid, Senior Level

3+ years exp

Telligen is one of the most respected population health management organizations in the country, and they are seeking a Senior Review Coordinator to conduct utilization review and medical management. The role involves training team members, performing medical record reviews, and ensuring compliance with health care standards.

Health Care

Culture & Values

No H1B

Responsibilities

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 reviewer

Coordinates and participates in peer-to-peer review 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 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

Performs miscellaneous duties as assigned