Senior Review Coordinator - Utilization Management (RN)

Telligen•Oklahoma City, OK

About The 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.

Requirements

Current RN license that is recognized in the relevant jurisdiction(s)or other certification directly relevant to the type of review performed
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

Nice To Haves

Knowledge of URAC standards

Responsibilities

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.
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.