New Mexico Licensed Utilization Reviewer

Job Summary

New Mexico Licensed Utilization Reviewer, a full-time position responsible for conducting Nursing Facility Level of Care determinations, performing utilization review activities, and ensuring compliance with Long Term Care Supports and Services criteria in a remote setting.

Key Responsibilities

• Conduct NF LOC evaluations and determinations, documenting approvals and denials in the case management system
• Review and approve or deny community benefit care plans based on established criteria and timelines
• Participate in state fair hearing procedures and refer cases for medical director review as needed

Required Qualifications

• Active Nursing license in NM or compact license (RN or LPN) with at least one year of relevant experience
• Medical Social Worker or therapist with a minimum of one year of relevant experience
• Preferred one year of experience in a managed care organization or health plan insurance environment
• Knowledge of state and federal regulations regarding patient records confidentiality
• Comfortable with electronic data entry and documentation processes