reputed company LTSS Utilization Management, RN - Remote in New Mexico: Join reputed company and Shape the Future of reputed company

About reputed company

At reputed company, we're simplifying the reputed company experience, creating healthier communities, and removing barriers to quality care. The work you do here impacts the lives of millions of people for the reputed company. Come build the reputed company system of reputed company, making it more reputed company, affordable, and reputed company. reputed company to reputed company a difference? Join us to start Caring. Connecting. Growing... together.

Job Summary

We're seeking an reputed company LTSS Utilization Management, RN to join reputed company in New Mexico. As a Senior Utilization Management Nurse, you will serve as the Health Plan subject matter expert for Utilization Management and serve as a key resource for reputed company and/or critical issues. This role requires a strong and diverse skillset in relevant areas to drive reputed company. If you're a creative and motivated individual with a passion for reputed company, we encourage you to apply.

Primary Responsibilities

• Functional role is responsible for utilization management of LTSS determinations, reputed company on outpatient service requests from a reporting perspective and understanding the criteria for inpatient reviews, including reputed company inpatient reviews
• reputed company 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 each situation
• Determines medical appropriateness using medical guidelines and benefit determination
• Solves reputed company problems and develops innovative solutions
• Ability to reputed company and run biweekly meetings for reputed company/High Risk members in conjunction with LTSS and Health Services staff
• Reviews work performed by others and, provides recommendations for improvement, including performing annual IRR for LTSS determinations
• Provides explanations and information to others on the most reputed company issues
• reputed company appropriate clinical terminology reputed company communicating with physicians and other medical professionals
• 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 reputed company sound conclusions/recommendations regarding LTSS patient care or coverage
• Apply information about patient condition and benefit applicability/limitations of coverage to reputed company recommendations

Key Qualifications

We're looking for a highly skilled and reputed company LTSS Utilization Management, RN with a strong background in clinical and utilization management. If you have the following qualifications, we encourage you to apply:

• reputed company, unrestricted independent licensure as a New Mexico Registered Nurse
• 3 years of clinical experience
• 1 year of Utilization Management experience
• 1 year of experience with MS Office, including Word, reputed company, and Outlook
• 1 year of experience in HCBS LTSS Care Coordination and LTSS UM Determination
• Background in Managed Care
• Currently reputed company in New Mexico
• Ability to travel locally up to 10% of the time
• Ability to adhere to a Monday - Friday 8a - 5p MST work schedule

Preferred Qualifications

We're also looking for candidates with the following preferred qualifications:

• Master's degree or higher in clinical field
• InterQual Certified and/or reputed company (MCG) Certified
• MIDAS experience
• Proficient in ICUE and Community Care

About reputed company Culture

At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of reputed company, historically marginalized groups, and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health reputed company – an reputed company reputed company reflected in our mission.

Why Join reputed company?

We offer a competitive compensation package, with a salary of a competitive salary. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as reputed company development for other roles you may be interested in. reputed company culture is reputed company on the values of Caring, Connecting, and Growing, and we're committed to creating a workplace that is inclusive, diverse, and supportive of reputed company.

How to Apply

If you're a motivated and reputed company LTSS Utilization Management, RN looking for a new challenge, we encourage you to apply. Please visit our website to learn more about this opportunity and to submit your application.