RN Utilization Review Case Manager
Albuquerque, NM
PRIDE Health
5x8 hrs
Referral Bonus

Job Opportunity: RN - Utilization Review / Case Manager

Location: Albuquerque, New Mexico
Employment Type: Clinical - Nursing
Contract Length: 13 weeks

Job Summary

Coordinate patient care across the continuum in a primarily inpatient setting, focusing on assessment, care planning, implementation, coordination, monitoring, and evaluation to achieve cost-effective and quality outcomes. Facilitate patient transfers between hospitals when services are available. Floating between departments and/or local locations within 20 miles is required.

Key Responsibilities

• Coordinate and facilitate patient transfers using established transfer center processes.
• Collect clinical information to determine patient level of care after admission decisions.
• Conduct comprehensive assessments including psychosocial, physical, medical, environmental, and financial factors.
• Collaborate with healthcare teams to develop, implement, and document treatment and discharge plans addressing social, physical, mental, emotional, spiritual, and supportive needs.
• Apply utilization review criteria to assess appropriateness of admission, continued stay, level of care, and readiness for discharge; refer non-qualifying cases to Physician Advisor.
• Promote appropriate use of clinical and financial resources to improve quality of care and patient satisfaction.
• Perform cost-benefit analyses and negotiate with non-contracted providers and vendors as needed.
• Generate reports demonstrating cost savings and outcome measures.
• Participate in developing clinical guidelines and pathways; educate providers and departments on health management and care coordination.
• Review and process requests for approval of pre-service and concurrent services, including hospitalizations, diagnostic testing, outpatient procedures, home health care, durable medical equipment, and rehabilitative therapies.
• Conduct retrospective reviews and audits at provider locations within New Mexico, ensuring accurate documentation.
• Compile detailed findings from medical record validations and audits for review.

Required Skills & Experience

• Minimum 5 years of clinical nursing experience.
• At least 2 years of recent experience (within the last 10 years) in Emergency or acute clinical settings, utilization review, or case management.
• Proficient with Windows, Word, Excel, and database systems.
• Ability to analyze trends using decision support systems.
• Business management skills including cost/benefit analysis, negotiation, and cost containment.
• Knowledge of referral coordination to community and private/public resources.

Education & Certifications

• Required: BSN degree.
• Required Licensure: New Mexico RN license.
• Required Certifications: BLS.
• Preferred: National certification within 3 years of hire (not mandatory).

Additional Notes

• Prior travel experience is not specified or required.
• Floating between departments and local locations within 20 miles is required.