Core Values Dedication ~ Ingenuity ~ Community ~ Integrity Section 2: Telligen’s Idaho QIO Organization Chart Section 3: Idaho Medicaid Review Team Positions UM/QM Responsibilities Qualifications Position Performs prospective, concurrent or Registered nurse or other retrospective utilization review/medical licensed healthcare professional management for all services including directly relevant to the type of appropriateness of Quality of Care review performed Senior based on contract, state, or URAC One to in two years’ experience Review requirements. Screens individual cases a healthcare setting Coordinator / according to specific criteria to Valid Idaho license Review determine if care is appropriate. Functional PC knowledge Coordinator Refers cases that fail to meet criteria to Knowledge of medical coding, peer review billing and/or utilization Enters medical information into management preferred system(s) Performs coding validation to ensure Experience with ICD coding and submitted diagnoses/procedures on concepts as well as CPT and claim are supported by clinical record HCPCS coding required documentation and appropriate billing Two years minimum experience Screens individual situations according in inpatient and/or outpatient Medical to applicable coding guidelines to coding. Coding determine if coding is appropriate Certified Professional Coder or Analyst Refers cases that fail to meet criteria to Certified Coding Specialist or peer reviewer Certified Coding Assistant or (future) Registered Health Information Performs preliminary research on topics Technician or Registered Health such as coverage determinations, Information Administrator coding guidelines or standards of care. required
Core Values Dedication ~ Ingenuity ~ Community ~ Integrity Section 2: Telligen’s Idaho QIO Organization Chart Section 3: Idaho Medicaid Review Team Positions UM/QM Position Responsibilities Qualifications Senior Review Coordinator / Review Coordinator 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 cases according to specific criteria to determine if care is appropriate. Refers cases that fail to meet criteria to peer review Enters medical information into system(s) Registered nurse or other licensed healthcare professional directly relevant to the type of review performed One to two years’ experience in a healthcare setting Valid Idaho license Functional PC knowledge Knowledge of medical coding, billing and/or utilization management preferred Medical Coding Analyst (future) Performs coding validation to ensure submitted diagnoses/procedures on claim are supported by clinical record documentation and appropriate billing Screens individual situations according to applicable coding guidelines to determine if coding is appropriate Refers cases that fail to meet criteria to peer reviewer Performs preliminary research on topics such as coverage determinations, coding guidelines or standards of care. Experience with ICD coding and concepts as well as CPT and HCPCS coding required Two years minimum experience in inpatient and/or outpatient coding. Certified Professional Coder or Certified Coding Specialist or Certified Coding Assistant or Registered Health Information Technician or Registered Health Information Administrator required
ProviderManual.docx