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    University of New Mexico - Hospitals 2h ago
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Hours Full-time, Part-time
Location Albuquerque, NM
Albuquerque, New Mexico

About this job

As a Manager of Secondary Review working with our NM Centennial Care members, you will be supervising and managing a team of Utilization Management Secondary Reviewers and clinical admin staff who are responsible for the determination of  HCBS and level of care for such services.
 
This is an office-based position in our Albuquerque office, working the hours of 8am - 5pm Monday through Friday.
 
Primary Responsibilities:

Manages and supports all UM Secondary Review activities related to the review and determination of HCBS based upon the comprehensive needs assessment and / or related clinical criteria
Reviews quality of documentation as part of the review process
Assists in the development and delivery of UM Secondary Review curriculum and training as part of initial hiring and ongoing refresher training for both secondary reviewers and care coordination staff
Compiles and analyzes reports, reviews trends and creates associated action plans to address performance on targeted metrics
Assures consistency in clinical decision making through the IRR and audit process
Acts as the UM Secondary Review subject matter expert and represents the team as it relates to secondary review processes and protocols
Meets regularly with UM Secondary Review staff to provide guidance, support and coaching as needed
Research and problem-solve inquiries received from Managers, Care Coordinators, members and their representatives, or other internal / external stakeholders
Reviews and updates authorizations and other data in the electronic case management system
Forecasts and plans staffing resource requirements
Routinely attends and audits internal practices related to the appeals and fair hearings processes
May provide testimony in appeals and fair hearings proceedings on behalf of a team member or for the purpose of offering support
Works closely with compliance and clinical leadership to discuss protocols and engagement of legal counsel as appropriate

Requirements

Required Qualifications:

Current and unrestricted RN license for the state of New Mexico; OR a New Mexico licensed Social Worker, Counselor or Marriage & Family Therapist; OR a New Mexico licensed Physical / Occupational / Rehab Therapist
Bachelor's Degree or higher level of education
2+ years of clinical experience
Strong familiarity with New Mexico’s Nursing Facility Level of Care and/or Home and Community Based Services
Intermediate proficiency with MS Word, Excel, Outlook
Preferred Qualifications:

Experience working with the Long Term Care population in New Mexico
Background that involves utilization review for LTC Home and Community Based Services or Third Party Assessor functions in a managed care
1+ year of leadership or management experience
Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm)
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
 
 
Job Keywords: RN, Nurse, Registered Nurse, license Social Worker, Counselor or Marriage & Family Therapist, licensed Physical, Occupational Rehab Therapist, Manager, leadership, lead, supervisor, manage, review, Utilization, secondary review, Albuquerque, San Pedro, NM, New Mexico