Care Review Clinician I (66168)

Professional Management Enterprises
United States, New Mexico, Albuquerque
Feb 11, 2025
Care Review Clinician I(RN or LPN)to work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities. This position isFULLY remote, but *MUST reside in New Mexico. The work schedule will be M-F 8:30am-5:00pm MST. Some weekends may be required. Essential Functions: Provides concurrent review and prior authorizations (as needed) according to policy for members as part of the Utilization Management team. Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures. Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long-Term Care. Maintains department productivity and quality measures. Knowledge/Skills/Abilities: Demonstrated ability to communicate, problem solve, and work effectively with people. Excellent organizational skill with the ability to manage multiple priorities. Knowledge of applicable state, and federal regulations. In-depth knowledge of Interqual and other references for length of stay and medical necessity determinations. Experience with NCQA. Required Education Required Education: Nursing Degree with RN or LPN licensure Required Experience 3-5 years Utilization Management experience in a HP setting. Minimum 0-2 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management. Required License** Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.