Utilization Management Nurse Specialist

3 weeks ago

Albuquerque, New Mexico, United States Presbyterian Healthcare Services Full time
Job Title: Utilization Management Nurse Specialist

We are seeking a skilled Utilization Management Nurse Specialist to join our team at Presbyterian Healthcare Services. As a Utilization Management Nurse Specialist, you will play a critical role in ensuring that services rendered to members meet clinical criteria and are delivered in the appropriate setting.

Key Responsibilities:

  • Perform clinical review to ensure that services rendered to members meet clinical criteria and are delivered in the appropriate setting.
  • Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
  • Perform care review both prospectively and retrospectively.
  • Assist providers and members with coordination of care to in-plan providers and preferred out-of-plan providers.
  • Validate and interpret medical documentation using evidence-based criteria sets.
  • Consult with PHP medical directors and refer for medical director decisions on cases not meeting clinical criteria.
  • Identify members with complex conditions requiring one-on-one case management and/or disease management services and refer appropriately to the Presbyterian Integrated Care Management program.
  • Conduct retrospective medical claims audits, including pre-existing condition determinations, review of coding and DRGs, medical necessity, and pricing.
  • Refer cases for Quality Management review and Special Investigative Review as indicated for quality of care issues and possible abuse/fraud.

Requirements:

  • NM Nursing license. RN preferred, but will consider LPN with at least 5 years of experience in UM, UR, claims auditing, or case management.
  • Eligible for certification within three years of hire as CCM, CPUR, Certified Medical Audit Specialist, or similar certification as approved by the manager.
  • BSN preferred, but not required. Prefer 1 year of experience in HMO/MCO, health plan insurance environment required, with expertise performing utilization management functions.

Why Work at Presbyterian?

As an organization, we are committed to improving the health of our communities. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan, and a growing multi-specialty medical group. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care), and Commercial health plans.

We value our employees' differences and find strength in the diversity of our team and community. We capture this in our Promise and CARES commitments. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke-free campuses.

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