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Insurance Utilization Reviewer Jobs in New Mexico

Hired by Matrix

RN Utilization Review

Portales, NM · On-site

Job Title: RN Utilization Review City: Portales State: NM Job Type: Travel Discipline: RN ... insurance coverage * Initiate ongoing communication with the resident and resident's family to ...

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 ...

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

$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 ...

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 ...

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 ...

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Insurance Utilization Reviewer information

What is an insurance utilization reviewer?

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 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 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 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 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

RN Utilization Review

Hired by Matrix

Portales, NM • On-site

Other

Re-posted 9 days ago

Job description

Job Title: RN Utilization Review
City: Portales
State: NM
Job Type: Travel
Discipline: RN
Speciality: Utilization Review
Facility Setting: Short Term Actut Care (STAC)
Accepting Locals per Radius Rule?: Yes
Contract Length: 13 weeks
Shifts: Days
Shift Details: Day 5x8-Hour
Weekly Schedule: 40 Hours
Certifications/License: Mandatory Experience:
  • Routine case management, discharge planning, swing bed coordinator and utilization review duties.
  • Evaluating and screening potential admissions to the facilities swing bed program
  • knowledgeable of criteria for Medicare, Medicaid, HMO, swing bed and private insurance coverage
  • Initiate ongoing communication with the resident and resident's family to assess discharge needs.
  • Actively involvement in daily rounds with bedside staff, physicians and ancillary team members
  • Communicate with physicians to ascertain their plans for a timely discharge.
  • document updates and discharge planning as an ongoing review.
  • Manage and collaborate with the healthcare team on swing bed placement and complete MDS documentation as necessary.
  • assist with obtaining referrals, prior authorization for Home Health Care, CME, SNF, acute rehab and appointments.
  • Educates physicians and staff regarding appropriate level of care/utilization and required documentation that meets admission status
  • Run Interqual for each IP and OBS patient admitted to the floor
Get in Touch:
We want to hear from you! If you think you'd be a good match, submit your resume and reach out to Shrishti at (201) 366-0647 to learn more.

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