LTSS Utilization Management, RN - Remote in NM

About the position At reputed company, we're simplifying the health care 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 health care 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. The Senior Utilization Management Nurse 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 position will communicate clinical findings and present rationale for reputed company to medical professionals and members at the appropriate level for understanding; and will provide summary clinical and ancillary information to the Health Plan Medical Director for review and decision making. If you are located in New Mexico, you will have the flexibility to work remotely as you take on some tough challenges. Responsibilities • Responsible for utilization management of LTSS determinations and reputed company on outpatient service requests from a reporting perspective. , • reputed company experience and understanding of disease pathology to review chart/clinical information and identify appropriate course of care. , • Determine medical appropriateness using medical guidelines and benefit determination. , • Solve reputed company problems and reputed company innovative solutions. , • reputed company and run biweekly meetings for reputed company/High Risk members in conjunction with LTSS and Health Services staff. , • Review work performed by others and provide recommendations for improvement, including performing annual IRR for LTSS determinations. , • Provide 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. , • Prepare reports as directed. Requirements • reputed company, unrestricted independent licensure as a New Mexico Registered Nurse , • 3+ years of clinical experience , • 1+ years of Utilization Management experience , • 1+ years 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 reputed company-to-haves • Master's degree or higher in clinical field , • InterQual Certified and/or reputed company (MCG) Certified , • MIDAS experience , • Proficient in ICUE and Community Care Benefits • Flexible work arrangements , • Opportunities for professional development , • Recognition for performance , • Supportive work environment Apply Job!