RN Case Manager & Utilization Review Specialist

Cibola General Hospital; Grants (NM); On-site; USD 85,000 - 110,000; Full time

Job summary

Cibola General Hospital in Grants, NM seeks a Case Manager / Utilization Review Nurse (RN) to coordinate patient care, discharge planning, and utilization reviews. The role blends clinical case management with regulatory compliance and payer guidelines to ensure safe transitions and efficient resource use.

You will work with physicians, patients, families, and payers, perform concurrent reviews, obtain authorizations, and contribute to denial prevention while documenting activities in the EHR.

Qualifications

• Active, unrestricted RN license in NM or a compact state.
• 2–3 years of recent acute care clinical experience.
• Strong knowledge of Medicare/Medicaid regulations and medical necessity criteria (MCG/InterQual).
• Proficient in electronic health records systems (Cerner preferred).

Responsibilities

• Coordinate patient care progression and discharge planning throughout hospitalization.
• Perform comprehensive assessments of clinical, psychosocial, financial, and discharge needs.
• Identify discharge barriers and collaborate with interdisciplinary teams to facilitate timely progression.
• Coordinate referrals to Home Health, LTC, SNF, DME, and community resources.
• Document all utilization review activities and payer communications in the EHR.
• Participate in UR Committee activities and provide education to staff on medical necessity documentation.

Skills

Critical thinking

Communication

Care coordination

Discharge planning

Multidisciplinary teamwork

Education

RN license

BSN preferred

Tools

Cerner

Job description

Cibola General Hospital in Grants, NM seeks a Case Manager / Utilization Review Nurse (RN) to coordinate patient care, discharge planning, and utilization reviews. The role blends clinical case management with regulatory compliance and payer guidelines to ensure safe transitions and efficient resource use.

You will work with physicians, patients, families, and payers, perform concurrent reviews, obtain authorizations, and contribute to denial prevention while documenting activities in the EHR.