Location: Albuquerque, NM
support providers, plans, purchasers, and consumers, and offer services to state and federal agencies and others to help them better manage health care under the existing system and to backss, plan for and implement broader system transformation. We collaborate with academic, government, and nonprofit partners on initiatives funded by NIH, CDC, AHRQ, BJA, SAMHSA, and others.
In short, we are changing healthcare at a fundamental level. Purpose Assess the medical necessity and quality of healthcare services by conducting prospective, concurrent, and retrospective utilization management reviews. Education BA/BS in a nursing field Years of Experience in Related Field Required3 years of clinical
(direct patient care) experience Preferred + 1 year of utilization Review experience Experience with developmentally disabled patients Licensure Required Current, active, unrestricted clinical licensure as required by the state of New Mexico.
Specialized Knowledge, Skills, and Abilities and/or Competencies Strong MS Office Suite proficiency and familiarity with database software programs Strong organizational skillinteractioncellent oral and written communications skillinteractioncellent interpersonal and problem-solving skills Ability to organize and coordinate multiple simultaneous tasks in a team environment Inter Qual Criteria experience Typical Job Duties and Responsibilities Apply
clinical review criteria, organizational policies, guidelines, and screens to determine the medical necessity of health care services.
Consult with physician/practitioner consultants when reviews fail clinical review criteria, guidelines, and screens. Refer cases to others when collaboration as required. Refer cases to management as needed. Provide clinical and/or review process subject matter expertise, respond to customers questions or concerns. If needed, conduct an outreach to consultants, community support coordinators, case managers, and/or providers for required additional information May perform quality assurance audits and other program support, as assigned by supervisor.
Participate in peer reviews Other duties as assigned Compensation Range: $65k - $85k. PDN-9ac5bc8c-6338-43c9-92c8-a7f5625fe7d0Remote working/work at home options are available for this role. For more details: jobs-search. org/marketing_albuquerque-c439811/clinical-reviewer-remote-must-be-resident-of-new-mexico-albuquerque_i1959027502
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