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, consulting with medical directors on cases that do not meet criteria
• Perform retrospective medical claims audits and streamline the prior authorization process to support patient outcomes

Required Qualifications

• Active New Mexico Nursing license
• 3-5 years of nursing experience
• 1-3 years of experience in utilization management, prior authorization, or case management
• Strong knowledge of healthcare terminology and clinical guidelines
• Proficiency with EHR and case management software