Senior Review Coordinator - Utilization Management (RN)

About the role

This position is responsible for conducting utilization review and medical management for all services, including training and mentoring other team members, performing preliminary research on requested topics, and providing technical assistance, medical record review, and support to provider staff and physician reviewers.

Responsibilities

• Perform prospective, concurrent, or retrospective utilization review and medical management for all services, including assessing the appropriateness and quality 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 a peer reviewer.
• Coordinate and participate in peer-to-peer review as warranted. With prior management approval, may deviate from criteria with proper justification to authorize the service.
• Serve as a liaison between peer reviewers, providers, facilities, and/or subscribers.
• Coordinate and participate in the 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 the workflow documentation system, ensuring data is accurate and timely.
• Assist in compliance reporting.
• Perform miscellaneous duties as assigned.

Requirements

• Current RN license that is recognized in the relevant jurisdiction(s) or other certification directly relevant to the type of review performed. Ability to obtain required license(s) in state(s) by a timeframe set by the business, not to exceed 6 months.
• Current RN license must be unrestricted. If there is a restriction allowed by a relevant jurisdiction, it must be of a type that, according to the Medical Director, does not affect the health professional’s ability to fulfill the roles and responsibilities of a reviewer.
• Four-year degree in health care or a two- or three-year degree in nursing or a related field and/or equivalent training and/or experience.
• 3–5 years of recent experience working in a clinical environment.
• 5% local and/or overnight travel.

Preferred Qualifications

• Knowledge of URAC standards.
• Oncology experience highly preferred.

About Us

Telligen is one of the most respected population health management organizations in the country. We offer clinical, analytical, and technical expertise to support local, Tribal, and national partners, state and federal government programs, employers, and health plans. 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 help shape the future of health. We value:

• 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.