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.
40% 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.
20% 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.
15% Performs preliminary research on topics such as experimental or cosmetic services, coverage determinations, coding or standards of care.
10% Documents review and special project results in workflow documentation system, ensuring data is accurate and timely.
10% Assists in compliance reporting.
5% Performs miscellaneous duties as assigned.
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.
Positions working on specific contracts may require U.S. Citizenship.
Knowledge of URAC standards preferred.
5% local and/or overnight travel.
Telligen and its affiliates are Affirmative Action and Equal Opportunity Employers.
Attention to Detail
Sensitivity level of information handled in position: high
Telligen - 14 months ago