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