Case Reviewer

As a Case Reviewer, you will be responsible for performing utilization review 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.

The Illinois Tailored Care Management Program helps individuals with complex health and social needs transition from nursing facilities and Specialized Mental Health Rehabilitation Facilities (SMHRFs) to community-based living. Through person-centered care management and coordinated support services, the program empowers members to live more independently and thrive in their communities.

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 Case Manager Supervisor

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

Performs miscellaneous duties as assigned

Bachelor’s degree in health or human services and/or equivalent experience

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

Knowledge of home and community-based services

Experience working in an insurance or managed care environment

Possess Intermediate PC skills including navigating electronic health records and other computer software

Experience with utilization review of medical services 

 

Telligen is one of the most respected population health management organizations in the country. We offer clinical, analytical, and technical expertise to support local, Tribal, and national partners, state and federal government programs, and employers and health plans.

 

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.

 

 

Benefits: A general description of the benefits and other compensation available for this position can be found in Telligen's Benefits Summary.

 

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.

  

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