Utilization Management Nurse Specialist
Company: Presbyterian Hospital (Albuquerque, N.M.)
Posted on: August 6, 2022
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
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
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
*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
*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
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
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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