Senior Review Coordinator RN Eligibility & Appeals
Iowa
State Health Solutions /
Full-Time /
Hybrid
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.
Over our 50-year history, health care has evolved - and so have we. What hasn't changed is our deep commitment to those we serve. Our success is built on our ability to adapt, respond to client needs and deliver innovative, mission-driven solutions.
Our business is our people and we’re seeking talented individuals who share our passion and are ready to take ownership, make an impact and helth shape the future of health.
Are you Ready?
We’re on a mission to transform lives and economies by improving health.
Ownership: As a 100% employee-owned company, our employee-owners drive our business and share in our success.
Community: We show up - for our clients, our communities and each other. Being a responsible corporate partner is part of who we are.
Ingenuity: We value bold ideas and calculated risks. Innovation thrives when we challenge the status quo and listen to diverse perspectives.
Integrity: We foster a respectful, inclusive, and collaborative environment built on trust and excellence.
Thank you for your interest in Telligen!
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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.
Telligen and our affiliates are Equal Opportunity Employers 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. We will not accept 3rd party solicitations from outside staffing firms.
