Senior Review Coordinator - Utilization Management (RN)

About the role

This position will conduct utilization review/medical management for all services, including training and mentoring team members and performing preliminary research.

Responsibilities

• Conduct prospective, concurrent or retrospective utilization review/medical management for all services, including appropriateness of 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 peer reviewer
• Cookordinate 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 liaison between peer reviewer, provider, facility and/or subscriber
• Cookordinate and participates 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

Requirements

Required Skills And Experience:

• 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 timeframe set by business not to exceed 6 months
• 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
• Four-year degree in health care or two- or three-year degree in nursing or related field and/or equivalent training and/or experience
• 3 - 5 years recent experience working in a clinical environment
• 5% local and/or overnight travel

Preferred Skills And Experience

Knowledge of URAC standards Oncology experience highly preferred