Utilization Management Nurse Specialist

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Presbyterian is seeking a Utilization Management Nurse Specialist

The UM Nurse Specialist conducts clinical reviews to ensure that services provided to members meet clinical criteria and are delivered in appropriate settings. Using clinical expertise, coordinates, documents, and communicates all aspects of utilization and benefit management, handling both prospective (pre-service and concurrent) and retrospective care reviews. They assist providers and members in coordinating care with in-plan providers and preferred out-of-plan providers. Responsibilities include validating and interpreting medical documentation using evidence-based criteria, consulting with PHP medical directors on cases that do not meet clinical criteria, and identifying members with complex conditions who may benefit from case management or disease management services, referring them as appropriate to a Care Management program. The role also includes conducting retrospective medical claims audits, covering coding and DRG reviews, medical necessity assessments, and pricing and referring cases for Quality Management or Special Investigative Review when quality-of-care issues or potential abuse/fraud are identified. Additionally, the nurse may perform on-call duties, occasionally audit entities delegated for utilization management, and play a pivotal role in streamlining the prior authorization process to reduce delays in care, ultimately supporting optimal patient outcomes.

Some key responsibilities include:

• The Prior Authorization Nurse is responsible for reviewing, verifying, and processing requests for the approval of pre-service and concurrent services, supplies, and procedures, including inpatient hospitalizations, diagnostic testing, outpatient procedures, home health services, durable medical equipment, and rehabilitative therapies. This role involves conducting retrospective reviews and performing on-site or desktop audits at provider locations throughout New Mexico, ensuring all documentation is accurate and complete. The nurse integrates coding principles and maintains objectivity in medical audit and care review activities. They monitor trends in utilization both under and over-utilization and identify potential quality-of-care issues, reporting them to management as needed.

• Effective communication with providers, PHP medical directors, and applicable departments is essential, and the nurse is evaluated on communication effectiveness through audits, satisfaction surveys, and 360 evaluations. They are required to meet departmental and regulatory turnaround times for prior authorizations, concurrent reviews, and retrospective reviews while adhering to Service Level Agreements (SLAs) and maintaining high productivity and quality standards.

Qualifications:

• An active New Mexico Nursing license is required.

• Candidate must have 3-5 years nursing experience and 1-3 years experience in utilization management, prior authorization, or case management.

• Strong knowledge of healthcare terminology, clinical guidelines, and insurance authorization processes; proficiency with EHR and case management software; and excellent communication, critical thinking, and organizational skills.

• For LPNs: An active New Mexico Nursing license is required.

• LPNs candidate with 3-5 years nursing experience and 1-3 years experience in utilization management, prior authorization, or case management; strong knowledge of healthcare terminology, clinical guidelines, and insurance authorization processes; proficiency with EHR and case management software; and excellent communication, critical thinking, and organizational skills will be considered.

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 you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of 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 more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in ourPromise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.