Graduate of accredited professional nursing program with current New Mexico RN license.
BSN or equivalent preferred. Masters in Nursing, Management, or Healthcare
Administration highly desirable. Demonstrated management/leadership skills. Three to
five years experience in supervision or management with 2 in utilization review, case
management, and/or QA preferred. At least five years clinical nursing experience.
Nationally recognized CM Certification, or by 3 years of hire.
Primary Job Functions
- Selects, trains, orients department staff (either directly or through delegation.). Develops standards of performance, evaluates performance, and initiates or makes recommendations for personnel actions. Acts as a resource for policies, procedures, and operational changes.
- Manages daily workflow and contributes to budget development and maintenance. Monitors volume of work and distributes workflow to meet timelines.
- Responsible for maintenance, preparation, and distribution of policies, procedures, guidelines, and/or benefits. Acts as a resource for policies, procedures, operational changes, standards, and criteria.
- Demonstrates leadership and acts as a role model in developing positive internal and external customer relations. Exemplifies and demonstrates commitment to PHS mission including vision, values, purpose and strategies.
- Mentors staff on health services coordination principles, UM, and decision-making skills.
- Prepares reports as required by the director, PHP, State, Federal and employer groups.
- Works with the Medical Directors and department director to evaluate and develop utilization management plan and/or benefits interpretation to insure that care meets the following: is delivered at the appropriate level, is medically necessary, is covered, and meets nationally recognized standards and criteria for Utilization Management and Quality of Care.
- Implements department QA/QI program that includes measurable goals, and identifies opportunities for unit efficiencies and reducing barriers to care. Monitors for over/underutilization.
- Interfaces with management staff of Provider Services, Claims, and Member Services to foster a cooperative working relationship.
- Works closely with Delegated Review Coordinators and Provider Services to support delegated groups and ensure consistency of practice and decision-making.
- Maintains professional growth and development through seminars, workshops, and professional affiliations.
Presbyterian Healthcare Services - 18 months ago