Senior Review Coordinator – Utilization Management, RN

Jobtailor; Iowa (LA); On-site; USD 85,000 - 105,000; Full time

Job summary

Jobtailor is seeking a qualified RN to perform utilization review and medical management across services, ensuring quality of care in line with URAC and state requirements. You will screen cases, coordinate peer reviews, and refer those that fail screening for physician input.

Additionally you will mentor team members, participate in appeals as directed, conduct preliminary research on topics like coverage determinations, and document results in the workflow documentation system, with potential

Qualifications

• Must hold a current RN license or equivalent in relevant jurisdiction
• 4-year healthcare degree or nursing/related field with equivalent training/experience
• 3–5 years recent clinical experience
• Willingness to travel up to 5% locally/overnight

Responsibilities

• Perform prospective, concurrent or retrospective utilization review/medical management for services based on contract, state or URAC requirements
• Screen cases to determine appropriateness of care
• Refer cases that fail screening to peer reviewer
• Coordinate peer-to-peer reviews and appeals as directed by management
• Serve as liaison between peer reviewer, provider, facility and subscriber
• Mentor team members and physician reviewers to ensure timely reviews and appeals
• Conduct preliminary research on topics such as coverage determinations or coding standards
• Document review results in workflow system and assist in compliance reporting
• Perform miscellaneous duties as assigned

Skills

Utilization Review

Medical Management

RN License

Clinical Experience

Peer Review Coordination

Education

Bachelor degree in healthcare

Nursing degree or related field

Tools

Workflow Documentation System

Job description

Perform 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.
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 liaison between peer reviewer, provider, facility and/or subscriber.
Coordinate 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.
Performs preliminary research on topics such as experimental or cosmetic services, coverage determinations, coding or standards of care.
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

• 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

Core Competencies

Demonstrates expertise in Utilization Review and Medical Management, ensuring compliance with state and URAC requirements while effectively coordinating peer reviews and appeals. Proficient in training and mentoring team members to uphold quality standards in healthcare services.

Highest-signal resume keywords

• Utilization Review
• Medical Management
• RN License
• Clinical Experience
• Peer Review Coordination

ATS Optimization Keywords

Hard Skills

• Utilization Review
• Medical Management
• Clinical Assessment
• Quality of Care Evaluation
• Compliance Reporting

Soft Skills

• Mentoring
• Communication
• Collaboration
• Problem-Solving

Certifications & Qualifications

• RN License

Industry Keywords

• Healthcare
• URAC Requirements
• Peer Review
• Coverage Determinations
• Coding Standards

Tools & Technologies

• Workflow Documentation System