New Mexico Licensed Utilization Nurse - job 1 of 2

Job Summary

A company is looking for a Utilization Management Nurse Specialist.

Key Responsibilities

• Conduct clinical reviews to validate and interpret medical documentation, ensuring services meet clinical criteria
• Coordinate and document utilization and benefit management, including prospective and retrospective care reviews
• Perform retrospective medical claims audits and assist in streamlining the prior authorization process

Required Qualifications

• An active New Mexico Nursing license is required
• 3-5 years of nursing experience and 1-3 years in utilization management, prior authorization, or case management
• Strong knowledge of healthcare terminology, clinical guidelines, and insurance authorization processes
• Proficiency with EHR and case management software
• For LPNs: An active New Mexico Nursing license and relevant experience will be considered