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As a Case Reviewer, you will be responsible for performing utilization reviews to authorize services for individuals enrolled in Medicaid. The utilization review process involves applying program policies, verifying medical, technical, and financial eligibility, and reviewing medical records to issue decisions regarding pre-authorization of services.
Essential Functions
- Provides review decisions for prospective reviews based on an established set of criteria.
- Screens situations according to specific criteria to determine if care is appropriate.
- Refers cases that fail to meet criteria to a Registered Nurse or Social Worker reviewer.
- Ensures review is conducted thoroughly and within specified timeframes.
- Serves as liaison among clinical reviewer, provider, facility, and/or subscriber.
- Documents medical information supporting decisions into the workflow documentation system, ensuring data is entered accurately and timely.
- Ensures quality customer service by responding to email and phone inquiries from providers and consumers.
Requirements
- Bachelor’s degree in the health or human services and at least 1 year of experience in utilization review or 1 year of experience evaluating, analyzing, researching and developing health care services, policies and programs preferred OR
- A high school diploma or equivalent may substitute for a bachelor’s degree with at least 3 years of experience in utilization review or 3 years of experience evaluating, analyzing, researching and developing health care services, policies and programs.
- Demonstrated ability working with confidential information and in a deadline-driven environment.
- Excellent verbal and written communication skills
- Comfortable with completing basic math functions.
- Attention to detail, analytical skills, and the ability to interpret medical documentation accurately.
- Possess intermediate PC skills including navigating electronic health records and other computer software.
- Ability to work independently and as part of a team.
- Organizational skills and time management.
- Experience in a community health care environment preferred.
- Experience with utilization review of medical services preferred.
- Satisfactory completion of medical terminology course preferred.
- Must reside in Iowa
Preferred Skills and Certifications
- Knowledge of home and community-based services preferred.
- Experience working in an insurance or managed care environment preferred.
- Possess Intermediate PC skills including navigating electronic health records and other computer software.
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!
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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.
As part of our commitment to health and safety, some roles may require additional health protocols (i.e. personal protective equipment or vaccination).
Telligen and our affiliates are Affirmative Action, 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.
Telligen does not accept 3rd party solicitations from outside staffing firms.
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