Sr. Review Coordinator - Utilization Management (RN)
About The Position
The Sr. Review Coordinator will be responsible for conducting utilization review/medical management for all services with intent to train/mentor other team members and perform preliminary research on requested topics. In addition, the incumbent may provide technical assistance, medical record review and support to provider staff and physician reviewers. 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 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.
Requirements
- Current RN license.
- 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.
Nice To Haves
- Acute hospital and/or ICU experience preferred.
- Knowledge of URAC/NCQA requirements preferred.
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.
Benefits
- As a 100% employee-owned company, our employee-owners drive our business and share in our success.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
501-1,000 employees
