Telecommut
What you'll do:
- Performs prospective, concurrent or retrospective utilization review/medical management for all services and quality of care based on contract, state or URAC requirements
- Refers cases that fail to meet criteria to peer reviewer
- Collaborates with team members and other health care professionals to develop, implement and complete quality improvement and special project or corrective action initiatives based on review results. This may include technical writing and coordinating the development of materials to promote and support the initiatives or performing extensive research on requested topics to develop projects
- Serves as liaison with internal and external customers to ensure projects, plans and/or products are completed satisfactorily
- Maintains positive relationships with internal and external clients to ensure continued participation
- Serves as a representative of the Company at external client meetings
- Trains and serves as a mentor to team members 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
- Candidates must hold an active California RN license or be prepared to obtain one immediately upon hire
- Two or three-year degree in nursing
- 5+ years recent experience working in a clinical or behavioral health environment (behavioral health care coordination, case management, or utilization review)
- Ability to advocate for patients while ensuring compliance with insurance, legal, and regulatory guidelines
- Functional PC knowledge
- High attention to detail
- Strong verbal and written communication skills
- Strong understanding of mental health diagnoses, substance abuse treatment, and utilization management criteria (e.g., InterQual, MCG)
- Knowledge of URAC standards
- Proficiency with Electronic Health Records (EHR) and utilization management software
- Significant experience in focused project(s) related to behavioral health
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.
