Job Description

Job Description

Job Description



Position: UTILIZATION REVIEW RN- Case Management (IN PERSON) - SIGN ON BONUS

Location: Alamogordo, NM **Onsite- In person (40 HRS)

Schedule: Days

Responsibilities:

• Meets expectations aligned with organizational competency models, including Leader of Self, Leader of Others, or Leader of Leaders.
• Conducts prior authorization reviews to assess whether proposed services are covered and medically necessary for the beneficiary.
• Promotes quality, cost-effective outcomes through prior authorization and concurrent review using evidence-based clinical guidelines.
• Identifies and escalates cases involving potential quality of care concerns, questionable admissions, or extended lengths of stay to the Medical Director.
• Refers beneficiaries with complex or chronic conditions for care coordination, including transition of care, disease management, and behavioral health support as appropriate.
• Adheres to all applicable HIPAA regulations to ensure the privacy and security of Protected Health Information (PHI).
• Maintains confidentiality of sensitive data and ensures compliance with national health information standards.
• Reviews and analyzes clinical documentation submitted by providers to determine medical necessity, appropriateness, and efficiency of services, procedures, and facility use.
• Conducts provider outreach to coordinate post-discharge care, encourage use of in-network services, support durable medical equipment needs, and perform necessary follow-up.
• Applies the nursing process and critical thinking skills to oversee services and evaluate care options.

Job Requirements:

• Graduate of an accredited vocational nursing program or equivalent required
• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) preferred

Experience:

• 3–5 years of nursing experience preferred
• Proficiency with Microsoft Office applications (Outlook, Teams, Word, Excel) required
• General computer proficiency required

Licenses/Certifications:

• Active LVN license in the state of employment or compact license required
• Active RN license in the state of employment or compact license preferred

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