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Remote Insurance Utilization Review Jobs in New Mexico

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Remote Insurance Utilization Review information

What is a remote insurance utilization review?

Remote insurance utilization review jobs involve evaluating medical records and treatment plans to determine whether healthcare services are medically necessary and covered by a patient’s insurance plan. Professionals in these roles, often nurses or other healthcare specialists, work from home and communicate with healthcare providers, insurance companies, and patients. Their main goal is to ensure that patients receive appropriate care while also helping insurance companies manage costs and comply with regulations.

What skills and qualifications are needed for a remote insurance utilization review specialist?

To thrive as a Remote Insurance Utilization Review Specialist, you need a strong understanding of medical terminology, clinical guidelines, and insurance policies—usually supported by a nursing or health-related degree and relevant licensure. Familiarity with electronic medical record (EMR) systems, insurance claims platforms, and utilization review software is essential. Strong analytical skills, attention to detail, and effective written communication are crucial soft skills for this role. These competencies ensure accurate case evaluations, compliance with regulations, and clear communication between healthcare providers and insurers.

How does a remote insurance utilization review professional collaborate with healthcare providers and insurance companies?

Remote insurance utilization review professionals regularly interact with healthcare providers to gather patient information, clarify treatment plans, and ensure that clinical documentation supports insurance requirements. They also communicate with insurance companies to advocate for patient care, provide necessary justifications, and resolve coverage issues. While the work is done remotely, collaboration typically occurs via secure email, phone calls, and virtual meetings, requiring strong communication and organizational skills to ensure timely and accurate exchange of information.

What is the difference between Remote Insurance Utilization Review vs Remote Claims Reviewer?

AspectRemote Insurance Utilization ReviewRemote Claims Reviewer
CredentialsTypically requires nursing or healthcare-related certifications, such as RN or licensed healthcare professionalUsually requires insurance or claims processing knowledge, sometimes with certifications like CPC or CPC-H
Work EnvironmentRemote, healthcare or insurance company settings, reviewing medical necessity and appropriateness of servicesRemote, insurance companies or third-party administrators, reviewing claims for accuracy and compliance
Industry UsageCommonly used in healthcare insurance to evaluate medical necessityUsed across insurance sectors to process and validate claims

Remote Insurance Utilization Review focuses on assessing the medical necessity of services, often requiring healthcare credentials. Remote Claims Reviewers handle claims processing and validation, emphasizing insurance knowledge. Both roles are remote and industry-specific but differ in their primary responsibilities and required qualifications.

What are popular job titles related to Remote Insurance Utilization Review jobs in New Mexico?

For Remote Insurance Utilization Review jobs in New Mexico, the most frequently searched job titles are:

What job categories do people searching Remote Insurance Utilization Review jobs in New Mexico look for?

The top searched job categories for Remote Insurance Utilization Review jobs in New Mexico are:

Remote Insurance Utilization Review jobs near you
Infographic showing various Remote Insurance Utilization Review job openings in New Mexico as of June 2026, with employment types broken down into 66% Full Time, 12% Part Time, and 22% Contract. Highlights an 100% Remote job distribution.

LTC Utilization Management Reviewer

Albuquerque, NM • On-site, Remote

Presbyterian Healthcare Services
Hospitals • 10K+ employees

7.2

Company rating: 7.2 out of 10

Based on 164 frontline employees who took The Breakroom Quiz

345th of 893 rated healthcare providers

Great coworkers

People enjoy working here

Good employer

Learn more about Presbyterian Healthcare Servicesexternal

$65K - $111K/yr

Full-time

Medical, Dental, Vision, Life

Posted 8 days ago

Job description

Location Address:
9521 San Mateo NEAlbuquerque, NM 87113-2237
Compensation Pay Range:
Minimum Offer $65,520.00Maximum Offer $111,612.80Now Hiring: LTC Utilization Management Reviewer
Summary:
Build your Career. Make a Difference. Presbyterian is hiring a skilled LTC Utilization Management Reviewer to join our team.Type of Opportunity: Full timeJob Exempt: YesJob is based: Reverend Hugh Cooper Administrative CenterWork Shift: Days (United States of America)
Responsibilities:
Now hiring a Utilization Management Reviewer-LTC
Responsible for conducting Nursing (NF) Facility Level of Care (LOC) determinations according to state regulations and criteria. Performs utilization review activities to ensure that services rendered to members meet Long Term Care Supports and Services (LTSS) criteria and services are delivered in the appropriate setting. Utilizes LTSS skills and established criteria to review, coordinate, document and approve all aspects of the utilization/benefit management program, including but not limited to community benefit care plans and self-directed community benefit care plans and budgets. Validates and interprets documentation using approved LTSS criteria. Consults with PHP medical directors and refers for medical director decisions on cases not meeting LTSS criteria, NF LOC denials and care plans that result in a reduction in service or benefit denial. Refers cases for Quality Management review and Special Investigative Review as indicated for quality of care issues and possible abuse/fraud
Some key responsibilities include:
  • NF LOC evaluations and determinations,
  • Responsible for the review of all required medical documentation against HSD criteria and to provide an objective evaluation and determination of NF LOC medical eligibility (approvals and denials).
  • Documents recommendations and NF LOC determinations (approvals, request for more information and denials in PHPs case management system, including appropriate documentation of authorization and NF LOC begin and end date eligibility spans according to established HSD policies. Refers all NF LOC denials to the health plans medical director for review.
  • Prepares files and participates in state fair hearing procedures.
  • Reviews agency-based community benefit care plans for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines. Approves (full or partial) or denies care plan according to criteria and available documentation
  • Documents Agency-based community benefit care plan approvals, partial approvals and denials in PHPs case management system according to policies and procedures and job-aids.
  • Reviews self-directed community benefit care plans and budgets for appropriateness according to established LTC benefit UM criteria and guidelines and according to required timelines. Approves (full or partial) or denies care plan according to criteria and available documentation
  • Reviews care plans to assure the overall cost of the community benefit care plan does not exceed the overall cost of care in a nursing home based on the benchmark provided by HSD.
  • Documents self-directed community benefit care plan and budget approvals, partial approvals and denials in PHPs case management system and the Fiscal Management agencys information system according to policies and procedures and job-aids.

Qualifications:
  • Active Nursing license in NM or compact license (RN or LPN) with a minimum of one year of relevant experience
  • Medical Social Worker with a minimum of one year of relevant experience; or
  • Physical, Occupational, or Rehab Therapists with a minimum of one year of relevant experience.
  • Prefer 1 year of experience in MCO, health plan insurance environment , with expertise performing utilization management or experience working in long term care services
  • Knowledge of all state and federal regulations concerning the use, disclosure, and confidentiality of all patient records.
  • Analytical skills as applicable to interpret provider communication and medical records.
  • Attention to detail and organizational skills.
  • Ability to articulate orally and in writing an understanding of complex issues and detailed action plans, while best
  • representing the organization professionally.
  • Ability to work cooperatively with other employees and departments.
  • Efficient and comfortable with computer electronic data entry and documentation
  • Ability to succinctly document using correct spelling and grammar.
  • Able to summarize from medical clinical notes, progress notes, needs assessments, functional assessments, progress notes, history and physicals , care plans and other state required documentation.
  • Able to meet timelines and deadlines associated with work load.

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.
We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services
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About Presbyterian Healthcare Services

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Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.

Industry

Hospitals

Company size

10,000+ Employees

Headquarters location

Albuquerque, NM, US

Year founded

1908

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