- CenterWell (Santa Fe, NM)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- Molina Healthcare (Albuquerque, NM)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals requests ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- Humana (Santa Fe, NM)
- …community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills to support the coordination, ... from medical records sent from Behavioral Health Facilities to obtain sufficient clinical information. The Utilization Management Behavioral Health Nurse 2 work… more
- Molina Healthcare (Rio Rancho, NM)
- …**Job Summary** The RN Care Review Clinician provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...intensive care unit, or in a telemetry type setting. UM medical review experience highly preferred. Work Hours: Monday… more
- Health Care Service Corporation (Albuquerque, NM)
- …education/local resource information and encourage member (self) education functioning in a clinical care advisory role, the primary nurse case administrator ... all other entities involved in managing specialty care. The primary nurse case administrator performs care coordination; identifies alternate treatment programs;… more
- Humana (Santa Fe, NM)
- …a part of our caring community and help us put health first** The Telephonic Nurse Case Manager will be a member of the In-Home Case Management Team, providing a ... beneficiary's capacity for self- care, to cost-effectively achieve desired clinical outcomes and to enhance quality of medical care....and to enhance quality of medical care. The **Telephonic Nurse Case Manager** will collect and document data to… more
- Highmark Health (Santa Fe, NM)
- …experience, or provider operations and/or health insurance experience + 1 year in a clinical setting **Preferred** + 5 years in UM /CM/QA/Managed Care + 1 year ... over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and… more
- Molina Healthcare (NM)
- … (LVN) or Licensed Practical Nurse (LPN) license in good standing OR a clinical license in good standing, such as LCSW, LPCC or LMFT (for Behavioral Health Care ... our New Mexico Medicaid recipients. Preference will be given to those whose UM experience is within another MCO like Molina; experience with Interqual/MCG guidelines… more
- Molina Healthcare (Roswell, NM)
- …national, state, and local laws and regulatory requirements affecting the medical and clinical staff. + Marketplace UM reviews + MD licenses required for ... appropriate care at the most effective setting. Evaluates the effectiveness of UM practices. Actively monitors for over and under-utilization. Assumes a leadership… more
- Molina Healthcare (Roswell, NM)
- …**Job Summary** The Care Review Clinician (RN) provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...a candidate with a RN licensure that has previous UM and Inpatient Hospital experience. Candidates with MCO experience… more
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