Conducts provider outreach to coordinate post-discharge care, encourage use of in-network services, support durable medical equipment needs, and perform necessary follow-up. Refers beneficiaries with complex or chronic conditions for care coordination, including transition of care, disease management, and behavioral health support as appropriate.
Numbers & Facts
Location
Farmington, NM
Description
Job Description
Job Description
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Position: UTILIZATION REVIEW RN- Case Management (IN PERSON) - Up to $25K SIGN ON BONUS
Location: Farmington, NM **Onsite- In person
Schedule: Days
Responsibilities:
Meets expectations aligned with organizational competency models, including Leader of Self, Leader of Others, or Leader of Leaders.
Conducts prior authorization reviews to assess whether proposed services are covered and medically necessary for the beneficiary.
Promotes quality, cost-effective outcomes through prior authorization and concurrent review using evidence-based clinical guidelines.
Identifies and escalates cases involving potential quality of care concerns, questionable admissions, or extended lengths of stay to the Medical Director.
Refers beneficiaries with complex or chronic conditions for care coordination, including transition of care, disease management, and behavioral health support as appropriate.
Adheres to all applicable HIPAA regulations to ensure the privacy and security of Protected Health Information (PHI).
Maintains confidentiality of sensitive data and ensures compliance with national health information standards.
Reviews and analyzes clinical documentation submitted by providers to determine medical necessity, appropriateness, and efficiency of services, procedures, and facility use.
Conducts provider outreach to coordinate post-discharge care, encourage use of in-network services, support durable medical equipment needs, and perform necessary follow-up.
Applies the nursing process and critical thinking skills to oversee services and evaluate care options.
Job Requirements:
Graduate of an accredited vocational nursing program or equivalent required
Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) preferred
Experience:
3–5 years of nursing experience preferred
Proficiency with Microsoft Office applications (Outlook, Teams, Word, Excel) required
General computer proficiency required
Licenses/Certifications:
Active LVN license in the state of employment or compact license required
Active RN license in the state of employment or compact license preferred