This position will be responsible for performing utilization review/medical management including prospective, concurrent and retrospective review for all services. Essential Functions:
- Provides independent review decision for prospective, concurrent or retrospective utilization review/medical management cases. Cases can consist of inpatient, outpatient, procedure, DME, and therapy services as well as appropriateness of quality of care based on contract, state or URAC requirements. Cases failing to meet criteria are referred to a peer reviewer. This individual will screen situations according to specific criteria to determine if care is appropriate
- Refers cases that fail to meet criteria to peer reviewer. Ensures review is conducted thoroughly and within specified timeframes. Serves as liaison among peer reviewer, provider, facility and/or subscriber
- Documents medical information supporting decisions into the workflow documentation system, ensuring data is entered accurately and timely
- Performs miscellaneous duties as assigned
Requirements:
- Valid LPN/RN license or other certification directly relevant to the type of review performed;
- 1 – 2 years experience in nursing in a clinical environment. For certain programs LPN’s shall perform services within the scope of licensure and nursing practice
- Functional knowledge of PC required
Preferred Skills
- Knowledge of medical coding and billing preferred
- Experience working in an insurance or managed care environment preferred
COMMITMENT TO SAFETY As part of our commitment to health and safety, some roles may require additional health protocols (i.e. personal protective equipment or vaccination) 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. Telligen and our affiliates are Affirmative Action, Equal Opportunity Employers (EOE/M/F/Vet/Disability), and E-Verify Participants. Telligen will not provide sponsorship for this position. If you will require sponsorship for work authorization now or in the future, we cannot consider your application at this time. Telligen does not accept 3rd party solicitations from outside staffing firms.
