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This position 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. In addition, the incumbent may provide technical assistance, medical record review and support to provider staff and physician reviewers.
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.
- With prior management approval, may deviate from criteria with proper justification to authorize the service.
- 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.
- Assists in compliance reporting.
- Performs miscellaneous duties as assigned.
Requirements
- Two- or three-year degree in nursing .
- 3 – 5 years recent experience working in a clinical or behavioral health environment
- This contract requires a valid California Nursing License or the ability to obtain this licensure.
- Because of the nature and immediacy of the work, the ability to maintain regular and predictable attendance is essential.
- Knowledge of URAC standards preferred.
- Strong understanding of mental health diagnoses, substance abuse treatment, and utilization management criteria (e.g., InterQual, MCG).
- Proficiency with Electronic Health Records (EHR) and utilization management software.
Skills:
- Positions working on specific contracts may require U.S. Citizenship.
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 help 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.
Telligen is an equal opportunity employer. Qualified applicants will be considered without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, protected veteran status, disability or any other protected class.
Telligen is committed to ensuring that our employment process is open to all individuals, and provides reasonable accommodations to individuals who need assistance during any part of the employment process due to a disability, medical condition, or physical or mental impairment. Reasonable accommodations are considered on a case-by-base basis.
If you need assistance to navigate Telligen’s careers website or to apply for a position, please send an email to [email protected]
We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
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