RN Case Manager / Utilization Review

Job Type


Full-time

Description



Working at Cibola General Hospital makes a big difference in our community!

Cibola General Hospital Rooted in Grants, NM - Your Community Hospital
Since opening our doors in 1959, Cibola General Hospital has been dedicated to meeting the healthcare needs of our region. As a critical access hospital in Grants, NM, we play an essential role in delivering care to surrounding rural communities, providing access to important medical services closer to home.

Many of our team members grew up right here in Cibola County. They understand the people we serve because they are part of this community, bringing a level of connection and compassion that shapes every patient experience.

Our Mission, Values, & Vision
At Cibola General Hospital , our mission is built on four guiding principles that shape every interaction and every decision we make:

• Compassion: Treating every patient with kindness, empathy, and understanding
• Accountability: Taking responsibility for delivering safe, thoughtful care
• Respect: Honoring the dignity and individuality of every person
• Excellence: Striving to provide high-quality care through continuous improvement

These values reflect our commitment to creating a healthcare experience that is personal, accessible, and meaningful for our entire community. Let our family CARE for your family.

Check Out CGH's Excellent Benefits - Part of Your Total Rewards Package in this Role!

Benefits


Upon enrolling in our medical plan, employees and their household dependents gain the privilege of accessing any of our services at any of our facilities without the need for a co-pay. Additionally, enjoy a zero co-pay fee for all generic medications, ensuring comprehensive and affordable healthcare for your family.


Key Benefits :

• Medical and Dental benefits, as well as voluntary Vision benefits.
• 403b Retirement Plan with employer match up to 3.5% vested at 2 years, and Roth IRA.
• Basic Life/ADD/FSA tax saving accounts for health and dependent care.
• Employee Assistance Program (EAP), voluntary long-term disability coverage.
• PTO (max rollover of 520 hours, new hires will access their PTO at 60 days), NM Sick leave.
• Holidays (6 days/year).

Housing Assistance & Fuel Stipend


For employees residing more than 65 miles from our facility, we offer an exciting choice between a fuel stipend or temporary housing, subject to availability.


Sign-on Bonus


$15,000

Relocation Bonus


Up to $5,000


Retention Bonuses


CGH offers retention bonuses of up to $3,500. These bonuses will be awarded every five years, starting from your fifth year as a full-time employee.

Tuition Reimbursement


Up to $5,250 per calendar year for approved programsUp to $10,000 for master's degree or higher in leadership roles

Certification Training Program


We are thrilled to announce that we will reimburse employees for approved and job-specific certifications, including ACLS, PALS, and EMT, for example, and will also be compensated for each certification obtained, which will be an additional $0.75 to your hourly rate for each one. This initiative is designed to support your professional growth and enhance your expertise in the field.


Employee Referral Plan
CGH rewards up to $2,000 to employees of the hospital and clinic who identify and refer potential applicants who are hired into approved positions. The referral incentive will be awarded only for applicants who are hired and successfully complete ninety (90) days of active employment in a regular full-time position in the following jobs: Registered Nurse, Medical Technologist / Medical Laboratory Technologist, Ultrasound Technologist, Radiologic Technologist, Pharmacist, Certified Registered Nurse Anesthetist, Physician, Physician's Assistant, and Nurse Practitioner.


Job Summary


The Case Manager / Utilization Review Nurse (RN) is responsible for coordinating patient care progression, discharge planning, and utilization review activities. This integrated role ensures appropriate levels of care, regulatory compliance, efficient resource utilization, and optimal patient outcomes.

The position combines clinical Case Management functions with Utilization Review responsibilities, including medical necessity reviews, inpatient and concurrent authorizations, concurrent reviews, denial prevention, and interdisciplinary collaboration. The Case Manager / Utilization Review Nurse serves as a liaison between patients, families, providers, payers, and post-acute resources to facilitate safe, timely, and cost-effective transitions of care while supporting hospital reimbursement integrity and compliance with Medicare, Medicaid, commercial payer, and regulatory requirements.

Case Management Responsibilities

• Perform comprehensive patient assessments to identify clinical, psychosocial, financial, and discharge planning needs.
• Coordinate patient care progression and discharge planning throughout the hospitalization.
• Identify barriers to discharge and collaborate with interdisciplinary teams to facilitate timely patient progression.
• Coordinate referrals and post-acute services, including:
• Home Health
• Long-Term Care (LTC)
• Skilled Nursing Facilities (SNF)
• Durable Medical Equipment (DME)
• Community resources and support services
• Collaborate with patients, families, providers, nursing staff, therapy services, and ancillary departments regarding discharge planning and transition needs.
• Provide patient and family education on discharge plans, available resources, and support services.
• Coordinate advance discharge planning for orthopedic surgical patients, ensuring timely referrals, equipment orders, and post-discharge services.
• Participate in interdisciplinary rounds and team meetings to discuss patient progression and discharge readiness.
• Ensure timely and accurate Case Management documentation in the electronic health record (EHR).

Utilization Review Responsibilities

• Perform concurrent and retrospective utilization reviews for patient admissions and continued stays using established medical necessity criteria (e.g., MCG, InterQual) and payer-specific guidelines.
• Determine and reassess appropriate patient status, including inpatient versus observation levels of care.
• Obtain inpatient and concurrent authorizations for services in accordance with payer requirements and established timelines.
• Obtain prior authorizations and manage authorization workflows for inpatient and outpatient services as assigned.
• Submit initial and concurrent clinical documentation to payers within required timelines.
• Communicate effectively with physicians and other providers regarding medical necessity, documentation requirements, level-of-care determinations, and alternative levels of care.
• Monitor for avoidable days, delays in care progression, and opportunities to improve patient throughput.
• Identify and proactively address potential denials and reimbursement risks.
• Assist with preparation and submission of denial appeals, including supporting clinical rationale and documentation.
• Document all utilization review activities, approvals, denials, authorizations, and payer communications accurately in the EHR.
• Monitor readmissions, avoidable days, and utilization trends to support quality improvement initiatives.
• Participate actively in Utilization Review (UR) Committee activities and related compliance initiatives.
• Provide education to providers and staff regarding medical necessity documentation and payer requirements.

Requirements

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license in New Mexico or a Compact State.
• Minimum of 2-3 years of recent acute care clinical experience.
• Strong knowledge of Medicare and Medicaid regulations, commercial payer guidelines, and medical necessity criteria (MCG and/or InterQual).
• Excellent critical thinking, analytical, and problem-solving skills.
• Strong verbal and written communication skills.
• Ability to work independently while managing multiple priorities in a fast-paced environment.
• Proficiency with electronic health record systems (Cerner preferred) and related software applications.

Preferred Qualifications

• Previous Case Management and/or Utilization Review experience in an acute care setting.
• Experience with inpatient and concurrent authorization management, concurrent reviews, denial prevention, appeals, discharge planning, and care coordination.
• Critical Access Hospital (CAH) experience preferred.
• Knowledge of CMS Conditions of Participation, utilization management best practices, and payer authorization processes.

Work Environment

• Acute care hospital setting.
• Combination of patient-facing and office-based responsibilities.
• Frequent interaction with interdisciplinary clinical teams, payers, patients, and families.
• Fast-paced, collaborative environment requiring effective prioritization and workflow management.

Core Competencies

• Clinical judgment and medical necessity review
• Care coordination and discharge planning
• Regulatory compliance and payer guideline knowledge
• Communication and interdisciplinary collaboration
• Time management and organizational skills
• Problem-solving and denial prevention strategies

Physical Requirements

• Ability to sit, stand, walk, and use standard office and computer equipment for extended periods.
• Ability to review electronic medical records and documentation efficiently.
• Occasional movement throughout patient care areas and hospital departments.

Inclusivity and Reasonable Accommodation:

Cibola General Hospital is an Equal Opportunity Employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status. Note that a criminal background check will be conducted periodically as a condition of ongoing employment. CGH will reasonably accommodate qualified individuals with a disability so that they can perform the essential functions of a job unless doing so causes a direct threat to these individuals or others in the workplace and the threat cannot be eliminated by reasonable accommodation, or if the accommodation creates an undue hardship for CGH. We also seek to provide reasonable accommodation for the interview process.