[Hiring] Senior Review Coordinator RN @Telligen

Role Description

As a Senior Review Coordinator RN, you 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. This role is a home-based role and is part-time working Saturdays and Sundays under 20 hours.

• Perform prospective, concurrent or retrospective utilization review/medical management for all services.
• Review for appropriateness 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 participate in peer-to-peer review as warranted.
• With prior management approval, 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.

Qualifications

• Four-year degree or two or three-year degree in nursing.
• 3+ years recent experience working in a clinical environment.
• Current California RN license or ability to obtain within 3 months of hire (company paid).
• Current RN license must be unrestricted and if there is a restriction that is allowed by a relevant jurisdiction, according to the Medical Director, it is of the type that does not affect the health professional’s ability to fulfill the roles and responsibilities of a reviewer.
• Ability to maintain regular and predictable attendance is essential.
• We are unable to consider candidates outside of the United States, candidates in the state of California, or those in US Minor outlying islands and territories.

Preferred Skills and Experience

• California RN License.
• Prior UM experience.
• Strong Oral/Written Communication.
• Professional Image.
• Attention to Detail.
• Teamwork Skills.
• Technical Expertise.
• Good Judgment.
• Relationship Building & Influencing.

Benefits

• A general description of the benefits and other compensation available for this position can be found in Telligen's Benefits Summary.
• As a 100% employee-owned company, our employee-owners drive our business and share in our success.
• We show up - for our clients, our communities and each other. Being a responsible corporate partner is part of who we are.
• We value bold ideas and calculated risks. Innovation thrives when we challenge the status quo and listen to diverse perspectives.
• We foster a respectful, inclusive, and collaborative environment built on trust and excellence.