Position: UTILIZATION REVIEW RN- Case Management (IN PERSON) - Up to $25K SIGN ON BONUS Location: Farmington, NM **Onsite- In person Schedule: Days Responsibilities: • Meets expectations aligned with organizational competency models, including Leader of Self, Leader of Others, or Leader of Leaders. • Conducts prior authorization reviews to assess whether proposed services are covered and medically necessary for the beneficiary. • Promotes quality, cost-effective outcomes through prior authorization and concurrent review using evidence-based clinical guidelines. • Identifies and escalates cases involving potential quality of care concerns, questionable admissions, or extended lengths of stay to the Medical Director. • Refers beneficiaries with complex or chronic conditions for care coordination, including transition of care, disease management, and behavioral health support as appropriate. • Adheres to all applicable HIPAA regulations to ensure the privacy and security of Protected Health Information (PHI). • Maintains confidentiality of sensitive data and ensures compliance with national health information standards. • Reviews and analyzes clinical documentation submitted by providers to determine medical necessity, appropriateness, and efficiency of services, procedures, and facility use. • Conducts provider outreach to coordinate post-discharge care, encourage use of in-network services, support durable medical equipment needs, and perform necessary follow-up. • Applies the nursing process and critical thinking skills to oversee services and evaluate care options. Job Requirements: • Graduate of an accredited vocational nursing program or equivalent required • Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) preferred Experience: • 3–5 years of nursing experience preferred • Proficiency with Microsoft Office applications (Outlook, Teams, Word, Excel) required • General computer proficiency required Licenses/Certifications: • Active LVN license in the state of employment or compact license required • Active RN license in the state of employment or compact license preferred #ZRAI