The Utilization Management Nurse will serve as the Health Plan subject matter expert for Utilization Management and serve as a key resource for complex and/or critical issues. This position will communicate clinical findings and present rationale for decisions to medical professionals and members at the appropriate level for understanding; and will provide summary clinical and ancillary information to the Health Plan Medical Director for review and decision making.
If you are located in the state of New Mexico, you will have the flexibility to work remotely* as you take on some tough challenges. This position is a remote - based position with a home - based office.
Primary Responsibilities
- Function is responsible for utilization management which includes Initial and Concurrent Utilization Reviews for LTSS
- Leverage experience and understanding of disease pathology (e.g., conditions, normal course of care for a condition) to review chart/clinical information, ask appropriate questions, and identify appropriate course of care in a given situation
- Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
- Anticipates customer needs and proactively develops solutions to meet them
- Solves complex problems and develops innovative solutions
- Reviews work performed by others and provides recommendations for improvement
- Authorizes deviations from standards
- Provides explanations and information to others on the most complex issues
- Leverage appropriate clinical terminology when communicating with physicians and other medical professionals
- Advocate with physicians and others for appropriate decisions (e.g., patient level of care changes) regarding patient betterment (e.g., care and service coverage, safety)
- Identify inconsistencies or illogical information in patient responses, provider orders or patient history information and take appropriate action
- Apply professional judgment, take initiative to follow up, and manage conversations to make sound conclusions/recommendations regarding patient care or coverage
- Apply information about patient condition and benefit applicability/limitations of coverage to make recommendations
- Generally work is self-directed and not prescribed
- Works with less structured, more complex issues
- Works with minimal guidance; seeks guidance on only the most complex tasks
- Coaches, provides feedback, and guides others
- Acts as a resource for others with less experience
Required Qualifications
- Current, unrestricted independent licensure as a New Mexico Registered Nurse
- 3+ years of clinical experience
- 1+ years of Utilization Management experience
- 1+ years of experience with MS Office, including Word, Excel, and Outlook
- 1+ year of experience in HCBS LTSS Care Coordination and LTSS UM Determination
- Experience in Managed Care
- Currently reside in New Mexico
- Valid driver's license and access to reliable transportation
- Ability to travel locally up to 10% of the time
- Ability to adhere to a Monday - Friday MST work schedule
Preferred Qualifications
- Master's degree or higher in clinical field
- InterQual Certified and/or Milliman (MCG) Certified
- MIDAS experience
- Demonstrated proficiency in ICUE and Community Care
The salary for this role will range from $60,200 - $107,400 annually based on full-time employment.