Registered Nurse - Utilization Management. Job in Albuquerque Musk Jobs in Albuquerque, NM

Join Our Team as a Registered Nurse in Utilization Management!

The Oncology Institute (NASDAQ: TOI) is at the forefront of advancing oncology by providing specialized, value-based cancer care. Established in 2007, we serve approximately 1.9 million patients through 100+ clinics and affiliate locations across five states. Our commitment to innovative, evidence-based cancer care is transforming the oncology landscape and enhancing patient lives.

At The Oncology Institute of Hope and Innovation, we prioritize delivering compassionate and accessible cancer care. As a Registered Nurse specializing in Utilization Management, you will play a critical role in ensuring patients receive timely and appropriate treatments that align with our core values: integrity, excellence, collaboration, and empathy. Your clinical expertise will help facilitate patient access to life-saving care and uphold the high standards we set for ourselves.

Position Overview:

As the Oncology Utilization Management Registered Nurse, you will report directly to the Director of Utilization Management Compliance. Your focus will be on ensuring that our patients receive high-quality and cost-effective therapeutic care in line with our mission, vision, and core values. Your key responsibilities will include making clinical care review determinations for our hematology and oncology patients to enhance access to essential treatments.

Key Responsibilities:
• Review cases for laboratory orders and diagnostic studies to ensure completeness of supporting documentation.
• Conduct pre-authorization reviews for services to confirm compliance with medical policy and contracts.
• Utilize evidence-based and value-based clinical guidelines, collaborating with UM Medical Directors to make utilization management decisions.
• Ensure timely notification of authorization decisions to patients and providers according to regulatory requirements.
• Work collaboratively with nursing, eligibility, and authorization teams to support continuity of care and improve patient outcomes.
• Maintain accurate documentation of utilization and case management activities, providing regular reports.
• Assist Claims teams in reconciling issues related to billing and coding.
• Adhere to policies and procedures, ensuring compliance with HIPAA and other regulatory mandates.
• Engage in utilization management pharmacy initiatives to promote preferred pathways.
• Participate in quality improvement initiatives to enhance service delivery.
• Contribute to process improvement and cost management initiatives.
• Ensure workflow procedures and guidelines are well-documented and communicated.
• Initiate changes in guidelines and policies when necessary.
• Collaborate across functions to optimize member outcomes.
• Engage in Regulatory and Internal Audits.
• Embody TOI core values by providing exceptional customer service and fostering a positive experience for patients and team members.

Qualifications:
• Strong verbal and written communication skills.
• Ability to work independently and complete tasks effectively.
• Problem-solving aptitude with the ability to handle challenging situations with professionalism.
• Excellent analytical and critical thinking skills with a keen attention to detail.
• Proficiency in Microsoft Office Suite and electronic medical software applications.
• Ability to maintain regular attendance.
• Effective presentation skills and the ability to address queries confidently.

Requirements:
• Bachelor's degree in Nursing (BSN) preferred.
• A minimum of three years of experience in Utilization Management.
• Current registered nurse license in good standing with relevant state regulatory body.
• Oncology experience is required.

Competitive Pay:
$80,000 - $95,000 USD