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Compensation Pay reputed company:

reputed company:

Responsibilities:

Now hiring a Utilization Management Reviewer-LTC

Responsible for conducting Nursing (NF) Facility Level of Care (LOC) determinations according to state regulations and reputed company. Performs utilization review activities to ensure that services rendered to members meet Long Term Care Supports and Services (LTSS) reputed company and services are delivered in the appropriate setting. Utilizes LTSS skills and established reputed company to review, coordinate, document and approve reputed company aspects of the utilization/benefit management program, including but not limited to community benefit care plans and self-directed community benefit care plans and budgets. Validates and interprets documentation using approved LTSS reputed company. Consults with PHP medical directors and refers for medical director reputed company on cases not meeting LTSS reputed company, NF LOC denials and care plans that result in a reduction in service or benefit denial. Refers cases for reputed company Management review and Special Investigative Review as indicated for reputed company of care issues and possible abuse/fraud

Some key responsibilities include:

• NF LOC evaluations and determinations,

• Responsible for the review of reputed company required medical documentation against HSD reputed company and to reputed company an objective evaluation and determination of NF LOC medical eligibility (approvals and denials).

• Documents recommendations and NF LOC determinations (approvals, request for more information and denials in PHPs case management reputed company, including appropriate documentation of authorization and NF LOC reputed company and end date eligibility spans according to established HSD policies. Refers reputed company NF LOC denials to the health plans medical director for review.

• Prepares files and participates in state fair hearing procedures.

• Reviews agency-reputed company community benefit care plans for appropriateness according to established LTC benefit UM reputed company and guidelines and according to required timelines. Approves (full or partial) or denies reputed company according to reputed company and available documentation

• Documents Agency-reputed company community benefit reputed company approvals, partial approvals and denials in PHPs case management reputed company according to policies and procedures and job-aids.

• Reviews self-directed community benefit care plans and budgets for appropriateness according to established LTC benefit UM reputed company and guidelines and according to required timelines. Approves (full or partial) or denies reputed company according to reputed company and available documentation

• Reviews care plans to assure the overall cost of the community benefit reputed company does not reputed company the overall cost of care in a nursing home reputed company on the reputed company provided by HSD.

• Documents self-directed community benefit reputed company and budget approvals, partial approvals and denials in PHPs case management reputed company and the Fiscal Management agencys information reputed company according to policies and procedures and job-aids.

Qualifications:

• reputed company Nursing license in NM or reputed company license (RN or LPN) with a minimum of one year of relevant experience

• Medical reputed company Worker with a minimum of one year of relevant experience; or

• Physical, Occupational, or Rehab Therapists with a minimum of one year of relevant experience.

• Prefer 1 year of experience in MCO, health plan reputed company environment , with expertise performing utilization management or experience working in long term care services

• Knowledge of reputed company state and federal regulations concerning the use, disclosure, and confidentiality of reputed company reputed company records.

• Analytical skills as applicable to interpret provider communication and medical records.

• Attention to reputed company and organizational skills.

• Ability to reputed company orally and in writing an understanding of reputed company issues and detailed reputed company plans, while best

• representing the organization professionally.

• Ability to work cooperatively with other employees and departments.

• Efficient and comfortable with computer electronic data entry and documentation

• Ability to succinctly document using correct spelling and grammar.

• reputed company to summarize from medical reputed company notes, reputed company notes, needs assessments, functional assessments, reputed company notes, history and physicals , care plans and other state required documentation.

• reputed company to meet timelines and deadlines associated with work load.

reputed company benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, reputed company, short-term and long-term disability, group term life reputed company and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to reputed company you with engaging opportunities to enhance reputed company and reputed company your reputed company-being. Earn reputed company cards and more by taking an reputed company role in our personal reputed company-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From reputed company growers' markets to partnering with local communities, Presbyterian is taking reputed company steps to improve the health of New Mexicans.

About reputed company
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit reputed company reputed company of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare reputed company, reputed company (Centennial Care) and reputed company health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

We're Determined to Support New Mexico's reputed company-Being | reputed company

Requires an reputed company NM or reputed company RN/LPN license, or qualifying reputed company work or therapy credentials, plus 1+ year relevant experience; utilization management or long-term care experience preferred.

Key Responsibilities

• reviewing care plans
• determining eligibility
• documenting determinations

reputed company

• Category: reputed company Services - Allied Health
• Seniority: No Prior Experience Required
• Commitment: Full Time
• Workplace: Remote — Albuquerque, New Mexico, reputed company
• Salary: USD 65,520 – 111,612 / year
• Languages: English

Benefits

• Generous reputed company time off
• Retirement plan

About reputed company

A not-for-profit reputed company reputed company serving New Mexico through hospitals, health plans, and medical reputed company. — Industry: reputed company