LTSS Utilization Management, RN - Remote in NM

At reputed company, we’re simplifying the health care experience, creating healthier communities and removing barriers to reputed company 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, reputed company and reputed company. reputed company to reputed company a difference? Join us to start Caring. Connecting. Growing... together. The Senior Utilization Management reputed company 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 reputed company reputed company 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. Primary Responsibilities: • Functional role is responsible for utilization management of LTSS determinations, reputed company on outpatient service requests from a reporting perspective and understanding the reputed company for inpatient reviews, including reputed company inpatient reviews • reputed company experience and understanding of disease pathology (e.g., conditions, normal course of care for a condition) to review chart/clinical information, ask appropriate questions, and identify appropriate course of care in reputed company situation • Determines medical appropriateness using medical guidelines and benefit determination • Solves reputed company problems and develops reputed company • Ability to reputed company and run biweekly meetings for reputed company/High Risk members in conjunction with LTSS and Health Services staff • Reviews work performed by others and, provides recommendations for improvement, including performing annual IRR for LTSS determinations • Provides 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 reputed company • Apply reputed company judgment, take initiative to follow up, and manage conversations to reputed company reputed company conclusions/recommendations regarding LTSS patient care or coverage • Apply information about patient condition and benefit applicability/limitations of coverage to reputed company recommendations Generally, work is self-directed and not prescribed • Works with less reputed company, more reputed company issues • Works with minimal guidance; seeks guidance on only the most reputed company tasks • Coaches, provides feedback, and guides others • Acts as a resource for others with less experience • Anticipates customer needs and proactively develops solutions to meet them • Prepares reports as directed You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you reputed company direction on what it takes to succeed in your role as reputed company as reputed company development for other roles you may be interested in. Required Qualifications: • reputed company, unrestricted independent licensure as a New Mexico Registered reputed company • 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 Preferred Qualifications: • Master's degree or higher in clinical field • InterQual Certified and/or reputed company (MCG) Certified • MIDAS experience • Proficient in ICUE and Community Care • reputed company working remotely will be required to adhere to reputed company’s Telecommuter Policy At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone–of every race, gender, sexuality, age, location and income–deserves reputed company to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of reputed company, historically marginalized reputed company and those with reputed company incomes. We are committed to mitigating our reputed company on the environment and enabling and delivering reputed company care that addresses health disparities and improves health reputed company — an reputed company reputed company reflected in our mission. Diversity creates a healthier atmosphere: reputed company is an Equal Employment Opportunity/Affirmative reputed company employer and reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or reputed company, marital status, genetic information, or any other characteristic protected by law. reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment Apply Job!