Teams at IPRO

Conduct utilization, quality, clinical study, and appeal-level reviews using medical records and electronic worksheets. Make level-one denial decisions, collect clinical data, support Medical Review Analysts and Physician Consultants, and assist administrative staff with training, problem-solving, procedures, technical guidance, and staff huddles. The role requires a New York State RN license, nursing education, and acute-care or utilization-review experience.

Conduct utilization and quality reviews, including admission screening, authorizations, discharge and waiver processing, concurrent and retrospective reviews, appeals, and clinical study data collection. Support medical review analysts and physician consultants, collaborate on mental health reporting, and assist administrative staff with training, problem-solving, and procedure clarification.

Performs complex healthcare data analyses, including MCO encounter data validation, quality assurance, and performance measurement. Develops queries, reports, and Tableau dashboards; translates business requirements into analytical solutions; and communicates results to clients and stakeholders. Identifies automation and workflow improvements while ensuring data accuracy, regulatory compliance, and timely deliverables. Supports HEDIS and CMS-related analytics and manages multiple projects in an office-based environment.