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Utilization Management Nurse Specialist

Company: Presbyterian Hospital (Albuquerque, N.M.)
Location: Albuquerque
Posted on: August 6, 2022

Job Description:

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 Type of Opportunity: Full Time
FTE: 1.000000
Exempt: Yes
Work Schedule: Weekday Schedule Monday-Friday Qualifications *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 Responsibilities *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. Benefits We offer more than the standard benefits!
Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!


Learn more about our employee benefits:





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. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.


Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.



About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. 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 - including more than 1,600 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.



About Our Regional Delivery System
Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.


We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.



About New Mexico
New Mexico continues to grow steadily in population and features a low cost-of living.


Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.


New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.


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

Keywords: Presbyterian Hospital (Albuquerque, N.M.), Albuquerque , Utilization Management Nurse Specialist, Executive , Albuquerque, New Mexico

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