Utilization Management Nurse Specialist

Presbyterian exists to improve the health of patients, members, and the communities we serve. We are 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 1600 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.

Now hiring a Utilization Management Nurse Specialist Albuquerque Metro Residents Only. The UM Nurse Specialist conducts clinical reviews to ensure that services provided to members meet clinical criteria and are delivered in appropriate settings. Using clinical expertise, coordinates, documents, and communicates all aspects of utilization and benefit management, handling both prospective (pre-service and concurrent) and retrospective care reviews. They assist providers and members in coordinating care with in-plan providers and preferred out-of-plan providers. Responsibilities include validating and interpreting medical documentation using evidence-based criteria, consulting with PHP medical directors on cases that do not meet clinical criteria, and identifying members with complex conditions who may benefit from case management or disease management services, referring them as appropriate to a Care Management program. The role also includes conducting retrospective medical claims audits, covering coding and DRG reviews, medical necessity assessments, and pricing and referring cases for Quality Management or Special Investigative Review when quality-of-care issues or potential abuse/fraud are identified. Additionally, the nurse may perform on-call duties, occasionally audit entities delegated for utilization management, and play a pivotal role in streamlining the prior authorization process to reduce delays in care, ultimately supporting optimal patient outcomes.

The Prior Authorization Nurse is responsible for reviewing, verifying, and processing requests for the approval of pre-service and concurrent services, supplies, and procedures, including inpatient hospitalizations, diagnostic testing, outpatient procedures, home health services, durable medical equipment, and rehabilitative therapies. This role involves conducting retrospective reviews and performing on-site or desktop audits at provider locations throughout New Mexico, ensuring all documentation is accurate and complete. The nurse integrates coding principles and maintains objectivity in medical audit and care review activities. They monitor trends in utilization both under and over-utilization and identify potential quality-of-care issues, reporting them to management as needed. Effective communication with providers, PHP medical directors, and applicable departments is essential, and the nurse is evaluated on communication effectiveness through audits, satisfaction surveys, and 360 evaluations. They are required to meet departmental and regulatory turnaround times for prior authorizations, concurrent reviews, and retrospective reviews while adhering to Service Level Agreements (SLAs) and maintaining high productivity and quality standards. In performing review and evaluation, the nurse assesses prior authorization requests for services, thoroughly reviewing clinical documentation such as medical histories, diagnostic results, and treatment plans to determine medical necessity and make informed authorization decisions. They document review outcomes accurately in electronic health records and case management systems and communicate authorization decisions to providers, patients, and insurance teams promptly. Complex cases are escalated to higher-level reviewers or physicians as necessary. The nurse collaborates closely with healthcare providers to clarify requests, gather additional documentation, and resolve discrepancies, serving as a valuable resource on authorization procedures and criteria. They ensure strict adherence to regulatory guidelines, internal policies, and payer requirements, staying updated on relevant healthcare regulations, insurance policies, and medical criteria changes. In quality improvement efforts, the nurse participates in quality assurance initiatives, identifies trends, suggests areas for improvement, and helps pinpoint training needs. This comprehensive role supports the efficient and effective management of prior authorization processes, contributing to streamlined care delivery and positive patient outcomes. Follow all departmental policies and procedures. Performs other functions as required