Case Reviewer

Telligen • Oak Brook, IL

1d • $27 - $33

About The Position

The Case Reviewer performs utilization review to authorize services for individuals enrolled in Medicaid. The work involves applying program policies, verifying medical, technical, and financial eligibility, and reviewing medical records to make decisions about pre-authorization of services.

The position supports the Illinois Tailored Care Management Program, which helps people with complex health and social needs transition from nursing facilities and Specialized Mental Health Rehabilitation Facilities (SMHRFs) to community-based living through person-centered care management and coordinated support services.

Requirements

• Bachelor’s degree in health or human services and/or equivalent experience.
• At least 1 year of experience in utilization review, or 1 year of experience evaluating, analyzing, researching, and developing health care services, policies, and programs.

Nice To Haves

• Knowledge of home and community-based services.
• Experience working in an insurance or managed care environment.
• Intermediate PC skills, including navigating electronic health records and other computer software.
• Experience with utilization review of medical services.

Responsibilities

• Provides decisions for prospective reviews using established criteria.
• Screens situations against specific criteria to determine whether care is appropriate.
• Refers cases that do not meet criteria to a Case Manager Supervisor.
• Ensures reviews are thorough and completed within specified timeframes.
• Serves as a liaison among clinical reviewers, providers, facilities, and/or subscribers.
• Documents medical information supporting decisions in the workflow documentation system, ensuring data is entered accurately and on time.
• Responds to provider and consumer email and phone inquiries to ensure quality customer service.
• Performs miscellaneous duties as assigned.

Benefits

• A general description of benefits and other compensation available for the position is available in Telligen's Benefits Summary.
• Telligen is a 100% employee-owned company; employee-owners drive the business and share in its success.

What This Job Offers

• Job Type: Full-time