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Insurance Utilization Reviewer Jobs in New Mexico

MTK Healthcare

RN-Case Manager

Portales, NM · On-site

$59 - $62/hr

Experience in Utilization Review and Discharge Planning * Knowledge of Medicare, Medicaid, HMO, Swing Bed, and Private Insurance coverage * Experience with InterQual criteria and MDS documentation ...

Presbyterian Healthcare Services

$36.41 - $62/hr

... insurance Loan forgiveness through the New Mexico Higher Education Department EPIC electronic ... utilization review or case management experience desirable. * National Case Management ...

Phsorg

$36.41 - $62/hr

... insurance Loan forgiveness through the New Mexico Higher Education Department EPIC electronic ... utilization review or case management experience desirable. * National Case Management ...

Phsorg

... insurance Loan forgiveness through the New Mexico Higher Education Department EPIC electronic ... utilization review or case management experience desirable. * National Case Management ...

Presbyterian Healthcare Services

... insurance Loan forgiveness through the New Mexico Higher Education Department EPIC electronic ... utilization review or case management experience desirable. * National Case Management ...

1 Legacy, Inc

Full Time UM RN

Clovis, NM

Interacts with external review agencies to insure compliance with regulations affecting financial reimbursement to the facility. Conducts performance improvement activities to improve utilization of ...

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Insurance Utilization Reviewer information

What are the key skills and qualifications needed to thrive as an Insurance Utilization Reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What are some common challenges faced by Insurance Utilization Reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What are Insurance Utilization Reviewers?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.
What are popular job titles related to Insurance Utilization Reviewer jobs in New Mexico? For Insurance Utilization Reviewer jobs in New Mexico, the most frequently searched job titles are:
What job categories do people searching Insurance Utilization Reviewer jobs in New Mexico look for? The top searched job categories for Insurance Utilization Reviewer jobs in New Mexico are:
Insurance Utilization Reviewer jobs near you

Utilization Review Nurse Health Plans - Case Management

CHRISTUS Health

Alamogordo, NM • On-site

Full-time

This job post has expired today. Applications are no longer accepted.

CHRISTUS Health rating

6.7

Company rating: 6.7 out of 10

Based on 526 frontline employees who took The Breakroom Quiz

530th of 887 rated healthcare providers

Job description

Summary:
This position has a remote option for those living close and will be able to come into the hospital as needed.
The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services "CMS" Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.
Responsibilities:
  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  • The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary.
  • Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines.
  • Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination.
  • Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary's member's health care for behavioral health care management.
  • Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
  • Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines.
  • Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.
  • Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up.
  • Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
  • Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate.
  • Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities.
  • Must be able to take after hour calls to meet business requirements as needed.

Job Requirements:
Education/Skills
  • Graduate of an accredited school of vocational nursing or equivalent required
  • Associate's (ADN) or Bachelor's (BSN) in Nursing preferred

Experience
  • 3 - 5 years of nursing experience preferred
  • Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required
  • General computer knowledge and capability to use computers required

Licenses, Registrations, or Certifications
  • LVN license in the state of employment or compact required
  • RN license in state of employment or compact preferred

Work Schedule:
5 Days - 8 Hours
Work Type:
Full Time

What CHRISTUS Health employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

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About CHRISTUS Health

Sourced by ZipRecruiter

CHRISTUS Health is a prominent name in the healthcare industry, with its headquarters situated in Irving, TX, USA. Established in 1999, the company has since been devoted to providing comprehensive care and extending the healing ministry of Jesus Christ. This not-for-profit health system primarily operates more than 600 healthcare services and programs, including long-term care facilities, health insurance products, community clinics, and outreach services, serving both urban and rural populations.

Industry

Outpatient health care

Company size

1,001 - 5,000 Employees

Headquarters location

Irving, TX, US

Year founded

1999

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