Senior Review Coordinator RN Eligibility & Appeals

As a Senior Review Coordinator, you will be responsible for for conducting utilization review/medical management for all services including training and mentoring other team members and performing preliminary research on requested topics.This position will take participate in the level of care eligibility appeal process, including testifying in appeal hearings.Typical hours will be M- F 8:00 am to 4:30 pm Central Time.

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. 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.
• Documents review and special project results in workflow documentation system, ensuring data is accurate and timely.
• Participate in the appeals process: writing appeal summaries, researching related issues, and testifying in appeal hearings.
• Assists in compliance reporting.
• Performs miscellaneous duties as assigned.

Requirements

• Licensed Registered Nurse in Iowa.
• Located in Des Moines or surrounding areas with an ability to be co-located with our customers if required.
• Good written and oral communication skills are required.
• Must have an ability to work independently as well as with a team and be self-directed in a fast-paced environment.
• Experience with HCBS waivers, PMIC facilities, ICF-ID facilities, and inpatient behavioral health services.
• Have the ability to travel 25% local travel.
• The successful candidate(s) will show an ability to contribute to a positive team environment and demonstrate an ability to perform high quality work efficiently. Must exhibit a high level of professionalism and customer service.
• Utilization Management experience highly preferred
• HCBS waiver experience highly preferred
• Knowledge of URAC standards preferred.
• Experience with state fair hearings preferred.

Who We Are: Telligen is one of the most respected population health management organizations in the country.  We work with state and federal government programs, as well as employers and health plans offering clinical, analytical, and technical expertise. Health has changed a lot through our 50-year history, but what has remained constant is that we care deeply about who we serve and what we do. Our success is built on our ability to adapt, respond to client needs, and offer innovative solutions. Our business is our people and we’re looking for talented individuals who not only believe in our mission but who are ready to take ownership and make a difference in the lives of people, in the world of health. Learn more about who we are and what we do at www.telligen.com/about-us Are you Ready? We’re on a mission to transform lives and economies by improving health and getting there means following through on our values of Ownership, Community, Ingenuity & Integrity.  Ownership: As a 100% employee-owned company, our employee-owners drive our business, our solutions, and share in our success. When employee-owners grow and thrive, we all win.Community: Putting others first and being a good corporate partner wherever we work, and play makes us who we are. We Show Up. For our clients, for our communities, and for each other.Ingenuity: We’re a team of passionate professionals driven by hard work and big ideas. We understand that high-value breakthroughs come from taking calculated risks. If it will benefit our clients and advance our mission, we’re all ears. We celebrate free-thinking and challenge the status quo, so brainstorm away! Integrity: Smiling faces (virtual or in-person) are the norm around here. We enjoy a friendly work environment where everyone is dedicated to mutual trust, respect, and excellence.  Thank you for your interest in Telligen!Follow us on Twitter, Facebook, and LinkedIn to learn more about our mission-driven culture and stay up to speed.
While we use artificial intelligence tools to enhance our initial screening process, all applications are thoroughly reviewed by our human recruitment team to ensure a fair and comprehensive evaluation of each candidate.As part of our commitment to health and safety, some roles may require additional health protocols (i.e.