UTILIZATION MGMT NURSE SPEC
Company: Presbyterian Healthcare Services
Location: Espanola
Posted on: May 13, 2022
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Job Description:
Overview:As a Utilization Management Specialist RN, you will
perform clinical review to ensure that services rendered to members
meet clinical criteria and are delivered in the appropriate
setting.You will utilize clinical skills to coordinate, document
and communicate all aspects of the utilization/benefit management
program and perform care review both prospectively and
retrospectively. You will also refer cases for Quality Management
review and Special Investigative Review as indicated for quality of
care issues and possible abuse/fraud.You'll join a supportive,
dynamic, proactive, and collaborative team that includes surgical
techs, nurses and physicians in the beautiful northern New Mexico
location of Espanola Valley. Just north of Santa Fe, Espanola is
nestled between the Jemez and Sangre de Cristo mountain ranges and
the meeting points of three rivers, the Rio Grande, the Rio Chama
and the Rio Santa Cruz.Discover what it's like to work at a
regional facility of Presbyterian by viewing this brief video:Make
your life's work count for more here! Join a team committed to
improving the health of our communities.Type of Opportunity: Per
Required Need (PRN)FTE: 0.001Exempt: YesWork Schedule: Varied Days
and HoursClinical Nursing #RN123Responsibilities: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. Skills and Abilities:Ability to articulate
orally and in writing an understanding of complex issues and
detailed action plans, while best representing the organization
professionallyAbility to work cooperatively with other employees
and departments. Efficient and comfortable with computer electronic
data entry and documentationAbility to succinctly document using
correct spelling and grammar. Able to summarize from medical
clinical notesAbility to assertively and professionally interact
with providers and compassionately assist membersDemonstrated
critical thinking skills as evidenced by experience, education,
and/or the pre-hire interview processOrganizational and Analytical
skills: Experienced analytical skills as applicable to interpret
provider contracts and medical records. Experience with detailed
research, coordination and organizational skills.Preferred but not
required:SKILL-Critical thinking and attention to detail.ICD 9 OR
10SKILL-Microsoft OfficePlanning and coordinating organizational
changeAnticipating & Addressing Customer NeedsEducating Employees,
Customers & Transferring KnowledgeFunctioning as an Effective
Contingent MemberDiagnosing & Resolving ProblemsAcquiring &
Applying Superior Skills to achieve Quality OutcomesFunctioning as
an Effective Team MemberQualifications:Education:Associate Degree
RequiredLicensure requirements:NM Nursing license (RN preferred,
but will consider LPN with at least 5 years experience in UM, UR,
claims auditing or case management)Credentials:Certified Case
ManagerCertifications 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.Benefits:Competitive
Salaries and Benefits effective day-one (for .45 FTE and above)
including:Medical, dental, and vision insuranceFlexible spending
accounts (FSAs)Access to a robust wellness program, including
nutrition coaching classes and free access to our on-site fitness
centerPaid time off (PTO)Retirement plans, including matching
employer contributionsContinuing education and career development
opportunitiesLife insurance and short/long term disability
programs.Location Differential PayLearn more about our employee
benefits:https://www.phs.org/careers/empoyee-benefits/Pages/default.aspxAbout
UsPresbyterian Healthcare Services is 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, it is the state's largest private employer with
approximately 11,000 employees.Presbyterian's story is really the
story of the remarkable people who have chosen to work here.
Starting with Reverend Cooper who began our journey in 1908, the
hard work of thousands of physicians, employees, board members, and
other volunteers brought Presbyterian from a tiny tuberculosis
sanatorium to a statewide healthcare system, serving more than
700,000 New Mexicans.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 MexicoNew Mexico's unique blend of Spanish, Mexican
and Native American influences contribute to a culturally rich
lifestyle. Add in Albuquerque's International Balloon Fiesta, Los
Alamos' nuclear scientists, Roswell's visitors from outer space,
and Santa Fe's artists, and you get an eclectic mix of people,
places and experiences that make this state great.Cities in New
Mexico are continually ranked among the nation's best places to
work and live by Forbes magazine, Kiplinger's Personal Finance, and
other corporate and government relocation managers like Worldwide
ERC.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 Healthcare Services, Santa Fe , UTILIZATION MGMT NURSE SPEC, Accounting, Auditing , Espanola, New Mexico
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