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Position: UTILIZATION REVIEW RN- Case Management (IN PERSON) – Up to $25K SIGN ON BONUS
Location: Farmington, NM **Onsite- In person
Schedule: Days
Responsibilities:
- Meets expectations aligned with organizational competency models, including Leader of Self, Leader of Others, or Leader of Leaders.
- Conducts prior authorization reviews to assess whether proposed services are covered and medically necessary for the beneficiary.
- Promotes quality, cost-effective outcomes through prior authorization and concurrent review using evidence-based clinical guidelines.
- Identifies and escalates cases involving potential quality of care concerns, questionable admissions, or extended lengths of stay to the Medical Director.
- Refers beneficiaries with complex or chronic conditions for care coordination, including transition of care, disease management, and behavioral health support as appropriate.
- Adheres to all applicable HIPAA regulations to ensure the privacy and security of Protected Health Information (PHI).
- Maintains confidentiality of sensitive data and ensures compliance with national health information standards.
- Reviews and analyzes clinical documentation submitted by providers to determine medical necessity, appropriateness, and efficiency of services, procedures, and facility use.
- Conducts provider outreach to coordinate post-discharge care, encourage use of in-network services, support durable medical equipment needs, and perform necessary follow-up.
- Applies the nursing process and critical thinking skills to oversee services and evaluate care options.
Job Requirements:
- Graduate of an accredited vocational nursing program or equivalent required
- Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) preferred
Experience:
- 3–5 years of nursing experience preferred
- Proficiency with Microsoft Office applications (Outlook, Teams, Word, Excel) required
- General computer proficiency required
Licenses/Certifications:
- Active LVN license in the state of employment or compact license required
- Active RN license in the state of employment or compact license preferred
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