- Humana (Santa Fe, NM)
- …and help us put health first** Humana Healthy Horizons in Ohio is seeking a Utilization Management Nurse 2 who utilizes clinical nursing skills to support ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are… more
- Molina Healthcare (NM)
- …of payment decisions. + Serves as a clinical resource for Utilization Management , Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals. ... SKILLS & ABILITIES:** + Minimum 3 years clinical nursing experience. + Minimum one year Utilization Review and/or Medical Claims Review . + Minimum two years… more
- LifePoint Health (Las Cruces, NM)
- …resources in the development of care, discharge planning and Utilization Review . * Utilization Management performs prospective, admissions, observation ... review according to standard policies and procedure. * Utilization Management reviews and analyze processes designed...desirable. * Current New Mexico licensure as a Registered Nurse . * Certification as CCM or ACM desired. *_EEOC… more
- Indian Health Service (Gallup, NM)
- …Services, Perioperative Services Department, Gallup, NM. Assistant Supervisory Nurse is responsible for supervising, managing, directing, coordinating, providing ... Surgery and CSR. The position reports to the Perioperative Supervisory Nurse . Responsibilities **This position is being announced concurrently under Direct Hire… more
- Fresenius Medical Center (Albuquerque, NM)
- …auditing activities. + Accountable for completion of the Annual Standing Order Review and Internal Classification of Disease (ICD) coding. + Manages clinic ... financials including efficient utilization of supplies or equipment and regular profits and...of supplies or equipment and regular profits and loss review . + Responsible for all required network reporting and… more
- Community Health Systems (Las Cruces, NM)
- …Oversight & Leadership** : Manage the daily operations of the Care Management / Utilization Review Department, including supervising care managers, social ... . **Licenses/Certifications:** + **Required: Current licensure as a Registered Nurse (RN) in the state of New Mexico, or...in a fast-paced environment. + Deep understanding of case management processes, utilization review , and… more
- Molina Healthcare (Roswell, NM)
- … and effective resource management . + Develops and implements a Utilization Management program and action plan, which includes strategies that ensure ... IT and data analysts to produce tools to report, monitor and improve Utilization Management . + Actively participates in regulatory, professional and community… more
- Evolent (Santa Fe, NM)
- …for operational performance of physician, nursing, and shared services staff in the utilization management value chain + Owns clinical rationale for ... point of responsibility for all clinical operations inclusive of nurse , physician, and shared services performance. and core work...utilization management decisions made by all clinical staff + Ensures… more
- CenterWell (Albuquerque, NM)
- …review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking...and reliable transportation. + Two years as a Registered Nurse with at least one-year of management … more
- Evolent (Santa Fe, NM)
- …team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and client policies and ... behind it. **What You'll Be Doing:** The Evolent Appeals Nurse team offers candidates the opportunity to make a...and regulations. * Practices and maintains the principles of utilization management and appeals management … more
- Magellan Health Services (Albuquerque, NM)
- …the management , direct supervision and coordination of clinical and/or nonclinical management staff, including utilization management and intensive care ... and on-going management of designated staff. + Performs care management review activities consistent with Magellan policies, procedures, and standards.… more
- Intermountain Health (Santa Fe, NM)
- …of 2 years' experience in acute clinical nursing setting + Knowledge of utilization management and case management principles preferred KNOWLEDGE, SKILLS, ... **Job Description:** The Pre-Access Prior Authorization RN provides timely review of authorization requests and/or review of denials to ensure medical necessity,… more
- Children's Home Healthcare (Las Cruces, NM)
- …authorizations for Home Health services from insurance company. 7. Attend quarterly Utilization Review meetings as designated by the Director of Professional ... on a 60 days basis per company policy. 9. Review /approve plan of care and all related documents prior...skills and willing to travel to patient homes + Utilization Management Experience + Reliable transportation for… more
- Molina Healthcare (Santa Fe, NM)
- …Active, unrestricted State Registered Nursing (RN) license in good standing. + Utilization Management Certification (CPHM) Certified Professional in Health Care ... and results across Molina Health Plans & Segments. **KNOWLEDGE/SKILLS/ABILITIES** + Review existing case management standards and processes and establishes… more
- Veterans Affairs, Veterans Health Administration (Albuquerque, NM)
- Summary This position is located in the Health Information Management (HIM) section at the New Mexico VA Medical Center. MRTs (Coder) are skilled in classifying ... encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education. Applies comprehensive… more