Clinical Utilization Management Nurse Expert
2 weeks ago
We are seeking a Clinical Utilization Management Nurse Expert. This position offers the flexibility of remote work.
The role involves conducting clinical evaluations to confirm that services provided to members align with clinical standards and are administered in suitable environments. Employing clinical expertise, you will coordinate, document, and communicate all facets of the utilization and benefit management program. This includes both prospective and retrospective care assessments. The prospective review encompasses pre-service and concurrent services and procedures. You will assist both providers and members in navigating care coordination with in-network and preferred out-of-network providers. Your responsibilities will include validating and interpreting medical documentation using evidence-based criteria. You will consult with medical directors and refer cases for medical director decisions when clinical criteria are not met. Additionally, you will identify members with complex health conditions that require personalized case management or disease management services and refer them to the Integrated Care Management program. The position also entails conducting retrospective medical claims audits, which may include evaluations of pre-existing conditions, coding reviews, medical necessity assessments, and pricing. You will refer cases for Quality Management review and Special Investigative Review as necessary for quality of care concerns and potential abuse or fraud. On-call assignments may be required occasionally. You may also conduct audits of entities responsible for utilization management functions.
Why Your Contribution Matters Here.
We appreciate the unique perspectives of our employees and recognize the strength that diversity brings to our team and community.
At Presbyterian, our actions are as significant as our objectives. It is the way we achieve our goals that truly counts, and this begins with our remarkable team. From Information Technology to Food Services and beyond, our non-clinical staff play a vital role in enhancing the healthcare experience for our patients and members.
- Reasons to Join Us:
- Full Time - Exempt: Yes
- Job is based at Cooper Center
- Work hours: Days
- Benefits: We provide a comprehensive benefits package that includes medical, wellness programs, vision, dental, paid time off, retirement plans, and more for full-time employees.
- Licensure requirements: NM Nursing license. RN preferred, but LPNs with a minimum of 5 years of experience in Utilization Management, Utilization Review, claims auditing, or case management will be considered.
- Preferred certifications: Eligible for certification within three years of hire as CCM, CPUR, Certified Medical Audit Specialist, or similar certification approved by management.
- For RNs: BSN preferred, but not mandatory. A minimum of 1 year of experience in HMO/MCO or health plan insurance environments is required, with expertise in utilization management functions such as prior authorization and medical claims review, including both prospective and retrospective assessments, and audits in office and hospital settings.
- Knowledge of state and federal regulations regarding the use, disclosure, and confidentiality of patient records.
- Strong organizational and analytical skills: Proven analytical abilities relevant to interpreting provider contracts and medical records, along with detailed research and coordination skills.
- Ability to communicate complex issues and detailed action plans effectively, both orally and in writing, while representing the organization professionally. Must work collaboratively with colleagues and departments.
- Proficient in electronic data entry and documentation.
- Ability to document succinctly with correct spelling and grammar, summarizing from clinical notes.
- Capable of assertively and professionally interacting with providers while compassionately assisting members.
- Demonstrated critical thinking skills as evidenced by experience, education, and/or the pre-hire interview process.
- Receive, review, verify, and process requests for approval of pre-service and concurrent services, supplies, and/or procedures, including but not limited to inpatient hospitalizations, diagnostic testing, outpatient services, home health care, durable medical equipment, and rehabilitative therapies.
- Conduct retrospective reviews and perform on-site or desktop audits at provider locations within New Mexico, ensuring all documentation is completed accurately.
- Integrate coding principles and apply objectivity in the execution of medical audits and care review activities.
- After completing medical record validation and other retrospective audits, compile detailed findings and relevant supporting documentation for review by the HealthCare Cost Management team.
- Inform management of potential trends in inappropriate utilization and other quality of care issues.
- Effectively communicate with providers, medical directors, and relevant departments as evaluated through supervisory audits, satisfaction surveys, and 360 evaluations.
- Meet departmental and regulatory turnaround times for prior authorizations, concurrent reviews, and internal Service Level Agreements while maintaining productivity and quality standards.
- Perform additional functions as required.
All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance, and other optional voluntary benefits.
Wellness Presbyterian's Employee Wellness rewards program is designed to provide engaging opportunities to enhance your health and activate your well-being. Participate in wellness activities like challenges, webinars, preventive screenings, and more to earn rewards.
Why Choose Presbyterian? We are dedicated to improving the health of our communities. From hosting local markets to collaborating with community partners, Presbyterian is actively working to enhance the health of New Mexicans.
About Presbyterian Healthcare Services Presbyterian exists to enhance the health of patients, members, and the communities we serve. We are a locally owned, not-for-profit healthcare system comprising nine hospitals, a statewide health plan, and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees, including over 1,600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide, offering Medicare Advantage, Medicaid (Centennial Care), and Commercial health plans.
Inclusion and Diversity Our culture emphasizes knowing and respecting our patients, members, and each other, captured in our Promise and CARES commitments.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke-free campuses.
Maximum Offer for this position is up to USD $44.49/Hr.Compensation DisclaimerThe compensation range for this role considers various factors, including experience, training, internal equity, and other business and organizational needs.
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