Utilization Management Nurse Specialist - job 1 of 2

Overview

Now hiring a Utilization Management Nurse Specialist

 

Albuquerque Metro Residents Only.

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.

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

• Full Time - Exempt: Yes
• Job is based Remote Rev Hugh Cooper Admin Center
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off

Ideal Candidate:  Bachelors.  NM Nursing license. 3-5 years nursing experience and 1-3 years experience in utilization management, prior authorization, or case management

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.

Responsibilities

• 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.

   

• In performing review and evaluation, the nurse assesses prior authorization requests for services, thoroughly reviewing clinical documentation such as medical histories, diagnostic results, and treatment plans to determine medical necessity and make informed authorization decisions. They document review outcomes accurately in electronic health records and case management systems and communicate authorization decisions to providers, patients, and insurance teams promptly. Complex cases are escalated to higher-level reviewers or physicians as necessary.

   

• The nurse collaborates closely with healthcare providers to clarify requests, gather additional documentation, and resolve discrepancies, serving as a valuable resource on authorization procedures and criteria. They ensure strict adherence to regulatory guidelines, internal policies, and payer requirements, staying updated on relevant healthcare regulations, insurance policies, and medical criteria changes.

   

• In quality improvement efforts, the nurse participates in quality assurance initiatives, identifies trends, suggests areas for improvement, and helps pinpoint training needs. This comprehensive role supports the efficient and effective management of prior authorization processes, contributing to streamlined care delivery and positive patient outcomes.

  Follow all departmental policies and procedures.

  Performs other functions as required

Benefits

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 ensure the patients, members and communities we serve can achieve their best health. We are a 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.

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

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 $45.82/Hr.

Compensation Disclaimer

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.