Senior Review Coordinator

Telligen•Ridgeland, MS

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 participates 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 participate 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. Perform preliminary research on topics such as experimental or cosmetic services, coverage determinations, coding or standards of care. Document review and special project results in workflow documentation system, ensuring data is accurate and timely. Assist in compliance reporting. Perform miscellaneous duties as assigned.

Requirements

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
Specific contracts may require valid, current and appropriate state RN license or certification directly relevant to the type of review performed.
Because of the nature and immediacy of the work, the ability to maintain regular and predictable attendance is essential.

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 participates 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 participate 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.
Perform preliminary research on topics such as experimental or cosmetic services, coverage determinations, coding or standards of care.
Document review and special project results in workflow documentation system, ensuring data is accurate and timely.
Assist in compliance reporting.
Perform miscellaneous duties as assigned.