Utilization Management Nurse

Summary

Join Brighton Health Plan Solutions (BHPS) as a Utilization Management Nurse - Prior Authorization and perform medical necessity reviews for prior authorization requests. Working remotely, you will conduct prospective utilization reviews, identify third-party liability, collaborate with healthcare partners, and provide referrals to other departments as needed. You will also develop documentation, prioritize cases, and present cases to the Medical Director. This role requires a current LPN or RN license, proficiency in Microsoft Office, and experience in utilization management within a managed care setting. The ideal candidate will possess experience with outpatient reviews and familiarity with URAC and NCQA standards. BHPS offers a diverse and welcoming work culture focused on inclusion and belonging.

Requirements

• Current licensed LPN or Registered Nurse (RN) with state licensure. Must retain active and unrestricted licensure throughout employment
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Must be able to work independently
• Adaptive to a high pace and changing environment
• Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
• Working knowledge of URAC and NCQA
• 2+ years’ experience in a UM team within managed care setting

Responsibilities

• Perform prospective utilization reviews and first level determinations for members using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures
• Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments
• Collaborates with healthcare partners to ensure timely review of services and care
• Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
• Triages and prioritizes cases and other assigned duties to meet required turnaround times
• Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements

Preferred Qualifications

• 3+ years’ experience in clinical nurse setting
• TPA Experience
• Experience with outpatient reviews including DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases