Utilization Management Nurse Specialist

The Utilization Management Nurse Specialist conducts clinical reviews to ensure services meet clinical criteria and are delivered appropriately. They coordinate all aspects of utilization, handling prospective, concurrent, and retrospective reviews. This involves validating medical documentation, consulting with medical directors on cases not meeting criteria, and identifying members who could benefit from case or disease management. The role also includes retrospective medical claims audits, covering coding and DRG reviews, medical necessity assessments, and pricing, referring cases for Quality Management or Special Investigative Review when needed. The nurse may perform on-call duties and audit delegated entities. Plays a key role in streamlining prior authorization processes to reduce delays and improve patient outcomes. The Prior Authorization Nurse reviews and processes requests for approval of various services and supplies, including hospitalizations, testing, and therapies. They perform on-site audits throughout New Mexico, integrate coding principles, and monitor utilization trends to report potential quality issues. They communicate with providers and medical directors, meeting regulatory turnaround times and maintaining high standards. This comprehensive role supports efficient prior authorization management, contributing to care delivery and positive outcomes.