Utilization Management Nurse Specialist

Now hiring a Utilization Management Nurse Specialist

Performs clinical review to ensure that services rendered to members meet clinical criteria and are delivered in the appropriate setting. Utilizes clinical skills to to coordinate, document and communicate all aspects of the utilization/benefit management program. Performs care review both prospectively and retrospectively. Prospective review includes pre-service and concurrent services and procedures. Assists providers and members with coordination of care to in plan providers and preferred out of plan providers. Validates and interprets medical documentation using evidence-based criteria sets. Consults with PHP medical directors and refers for medical director decisions on cases not meeting clinical criteria. Identifies members with complex conditions requiring one on one case management and/or disease management services and refers appropriately to the Presbyterian Integrated Care Management program. Conducts retrospective medical claims audits including, but not limited to, pre-existing condition determinations, review of coding and DRGs, medical necessity, and pricing.. Refers cases for Quality Management review and Special Investigative Review as indicated for quality of care issues and possible abuse/fraud. Performs occasional on-call assignments. May perform, audits of entities delegated for utilization management functions

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

• Licensure requirements: NM Nursing license . RN preferred, but will consider LPN with at least 5 years experience in UM, UR, claims auditing or case management
• Certifications preferred: Eligible for certification within three years of hire as CCM, CPUR, Certified Medical Audit Specialist [or other nationally recognized nurse auditor certification], or similar certification as approved by the manager.
• For RNs: BSN preferred, but not required. Prefer 1 year of experience in HMO/MCO, health plan insurance environment required, with expertise performing utilization management functions (i.e., prior authorization, medical claims review to include prospective and retrospective review, office and hospital audits), experience in the principles of coding including the applicability and interpretation of ICD-9CM diagnosis coding, CPT and HCPCS Level II Coding, experience in generally accepted auditing principles and practices as they may apply to billing audits, billing claims forms, including the UB-04 [CMS-1450] and CMS 1500 forms and charging and billing procedure, OR prefer experience in home health, case management, or quality management
• Knowledge of all state and federal regulations concerning the use, disclosure, and confidentiality of all patient records.
• Organizational and Analytical skills: Experienced analytical skills as applicable to interpret provider contracts and medical records.
• Experience with detailed research, coordination and organizational skills.
• Ability to articulate orally and in writing an understanding of complex issues and detailed action plans, while best representing the organization professionally.
• Ability to work cooperatively with other employees and departments. Efficient and comfortable with computer electronic data entry and documentation
• Ability to succinctly document using correct spelling and grammar. Able to summarize from medical clinical notes
• Ability to assertively and professionally interact with providers and compassionately assist members
• Demonstrated critical thinking skills as evidenced by experience, education, and/or the pre-hire interview process

• Receives, reviews, verifies, and processes requests for approval of pre-service and concurrent services, supplies, and/or procedures., including but not limited to, inpatient hospitalizations, diagnostic testing, outpatient procedures and services, home health care services, durable medical equipment, and rehabilitative therapies,
• Performs retrospective review and conducts on-site or desktop audits at provider locations within New Mexico and completes all documentation accurately and appropriately.
• Integrates coding principles and applies principles of objectivity in performance of medical audit and care review activities.
• Upon completion of medical record validation and other retrospective audits, compiles detailed findings and relevant supporting documentation for review by the HealthCare Cost Management team. (HCCM)
• Advises manager of possible trends in inappropriate utilization (under and/or over), and other quality of care issues.
• Communicates effectively with providers, PHP medical directors, PHP/PIC departments, and applicable PHS departments as evaluated through supervisory audits, satisfaction surveys, and 360 evaluations, as applicable.
• Meets departmental and/or regulatory turnaround times for prior authorizations, concurrent review, and internal Service Level Agreements. (SLA) while maintaining productivity and quality standards.
• Performs other 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 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 our Promise and CARES commitments.

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