LTC Utilization & Care Plan Reviewer

Presbyterian Healthcare Services; Albuquerque (NM); On-site; USD 66,000 - 112,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Disability insurance

Life insurance

Wellness program

Job summary

Presbyterian Healthcare Services is seeking a skilled LTC Utilization Management Reviewer to join our team in Albuquerque, NM. This full-time exempt position focuses on NF LOC determinations and LTSS criteria to ensure appropriate care settings for members.

Responsibilities include conducting utilization reviews, coordinating with medical directors, and documenting approvals/denials in Presbyterian's case management system.

Qualifications

• Active NM or compact nursing license (RN or LPN) with at least 1 year of relevant experience.
• Medical Social Worker background with at least 1 year of relevant experience; or Physical, Occupational, or Rehab Therapists with at least 1 year of relevant experience.

Responsibilities

• Perform NF LOC evaluations and determinations per state LTSS criteria.
• Review medical documentation to determine NF LOC eligibility (approvals/denials).
• Document recommendations and determinations in the case management system with dates and approvals.
• Participate in state fair hearing procedures when required.
• Review LTC benefit plans for appropriateness and timelines; approve or deny per criteria.

Skills

RN/LPN NM license

Medical Social Worker

Therapist (PT/OT/REHAB)

Job description

Presbyterian Healthcare Services is seeking a skilled LTC Utilization Management Reviewer to join our team in Albuquerque, NM. This full-time exempt position focuses on NF LOC determinations and LTSS criteria to ensure appropriate care settings for members.

Responsibilities include conducting utilization reviews, coordinating with medical directors, and documenting approvals/denials in Presbyterian's case management system.