- CenterWell (Santa Fe, NM)
- …RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability ... Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare… more
- Humana (Santa Fe, NM)
- **Become a part of our caring community and help us put health first** The Utilization Management Nurse 2 utilizes clinical nursing skills to support the ... documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are… more
- Molina Healthcare (Santa Fe, NM)
- …ensure appropriate reimbursement to providers. + Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) ... modification of payment decisions. + Serves as a clinical resource for utilization management , CMOs, physicians and member/provider inquiries/appeals. + Provides… more
- Molina Healthcare (Santa Fe, NM)
- …reports submitted to the Eastern US Quality Improvement Collaborative (EQIC) and/or utilization management committees. + Participates as needed in joint ... **JOB DESCRIPTION** **Job Summary** The Delegation Oversight Nurse provides support for delegation oversight quality improvement activities. Responsible for… more
- Evolent (Santa Fe, NM)
- …Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are performed ... medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care across the continuum… more
- Intermountain Health (Santa Fe, NM)
- …cost-effective outcomes. Provides focused support to various areas such as utilization management , emergency department, acute, ambulatory and specialty care. ... in examining patterns of health care needs, decisions, lifestyle choices, and utilization of resources that affect their health. + Advocates, educates and coaches… more
- Molina Healthcare (Santa Fe, NM)
- …of health care services provided to plan members. * Supports plan utilization management program and accompanying action plan(s), which includes strategies ... the most appropriate care at the most effective setting. *Evaluates effectiveness of utilization management (UM) practices - actively monitoring for over and… more
- Molina Healthcare (Santa Fe, NM)
- …3-5 years clinical practice with managed care, hospital nursing or utilization management experience. **Preferred License, Certification, Association** Active, ... Any of the following: Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN) or...unrestricted Utilization Management Certification (CPHM). To all current Molina employees: If… more
- Highmark Health (Santa Fe, NM)
- …Inc. **Job Description :** **JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of health ... RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). + Delaware RN license must...is part of the compact **Preferred** + Certification in Utilization Management or a related field **SKILLS**… more
- Molina Healthcare (Santa Fe, NM)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... or emergency room. Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of… more
- CVS Health (Santa Fe, NM)
- …- 3+ years of acute experience as a Registered Nurse - 1+ years of Utilization Management experience - Must have experience using MS Office suites - Must be ... year - Occasional travel less than 5% to complete audits/meetings - Utilization Management is a 24/7 operation and work schedules will include weekends,… more
- Sharecare (Santa Fe, NM)
- …/ new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical, ... + Claims adjustments + Grievances and appeals submissions + Utilization management intake or status + Complex...and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case… more
- Datavant (Santa Fe, NM)
- …function as delegated by management Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade denials and appeal ... of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for...expertise successfully. Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in… more
- Highmark Health (Santa Fe, NM)
- …and education or if necessary involve Special Investigation Unit or the Utilization Management area. **ESSENTIAL RESPONSIBILITIES** + Implement the pre-payment ... itemized bills, and claims data to assure appropriate level of payment and resource utilization . It is also used to identify issues which can be used for education… more
- Molina Healthcare (Santa Fe, NM)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is a Remote position, home office with internet connectivity of high… more
- GE Aerospace (Santa Fe, NM)
- …does not directly own infrastructure platforms. The role accelerates digital utilization by standardizing data models, establishing reusable patterns, ensuring high ... data models, semantic layers, and reusable transformation patterns. **Data Management and Governance** + Implement data governance with domain-aligned stewardship,… more
- Oracle (Santa Fe, NM)
- …alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding, and various nurse chart review and documentation optimizations. The ideal candidate ... sessions, and offer ongoing consultation to support user proficiency and system utilization . Monitor project outcomes, track key metrics, and report progress to… more
- Molina Healthcare (Santa Fe, NM)
- …with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. Required Qualifications * At ... managed care, or equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in state of practice.… more
- Genesis Healthcare (Santa Fe, NM)
- …among residents of skilled nursing and senior living facilities. Our physicians, nurse practitioners (NPs) and physician assistants (PAs) are supported by a clinical ... assigned Centers and AlignMed Partners managers to oversee the implementation, utilization , and outcomes measurement of AlignMed Partners Clinical Programs and… more
- Genesis Healthcare (Santa Fe, NM)
- … Management and AlignMed Partners to oversee the implementation, utilization , and outcomes measurement of AlignMed Partners Clinical Programs. The Medical ... among residents of skilled nursing and senior living facilities. Our physicians, nurse practitioners (NPs) and physician assistants (PAs) are supported by a clinical… more