New Mexico Licensed Utilization Nurse

Job Summary

A company is looking for a Utilization Management Nurse Specialist.

Key Responsibilities

• Conduct clinical reviews to ensure services meet clinical criteria and are delivered appropriately
• Validate and interpret medical documentation using evidence-based criteria, and consult with medical directors on cases
• Perform retrospective medical claims audits and streamline the prior authorization process to enhance patient outcomes

Required Qualifications

• Active New Mexico Nursing license
• 3-5 years of nursing experience and 1-3 years in utilization management, prior authorization, or case management
• Strong knowledge of healthcare terminology, clinical guidelines, and insurance authorization processes
• Proficiency with EHR and case management software
• For LPNs: similar experience and qualifications as above will be considered