Presbyterian Healthcare Services - Albuquerque, NM

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Minimum Skills/Requirements

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 - save job - block
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