Now hiring a Utilization Management Reviewer-LTC
Responsible for conducting Nursing (NF) Facility Level of Care (LOC) determinations according to state regulations and criteria. Performs utilization review activities to ensure that services rendered to members meet Long Term Care Supports and Services (LTSS) criteria and services are delivered in the appropriate setting. Utilizes LTSS skills and established criteria to review, coordinate, document and approve all aspects of the utilization/benefit management program, including but not limited to community benefit care plans and self-directed community benefit care plans and budgets. Validates and interprets documentation using approved LTSS criteria. Consults with PHP medical directors and refers for medical director decisions on cases not meeting LTSS criteria, NF LOC denials and care plans that result in a reduction in service or benefit denial. Refers cases for Quality Management review and Special Investigative Review as indicated for quality of care issues and possible abuse/fraud
How you belong matters here.
We value our employees' differences and find strength in the diversity of our team and community.
At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.
Why Join Us
Ideal Candidate:
All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.
Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.
Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.