Utilization Management Nurse
Brighton Health Plan Solutions, LLCChapel Hill, NC
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Overview
Schedule
Full-time
Education
Nursing (RN, LPN)
Career level
Senior-level
Remote
Remote
Benefits
Health Insurance
Job Description
About The RoleBHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.Primary Responsibilities Performs clinical utilization reviews 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 standardsIdentifies potential quality of care issues, service or treatment delays and intervenes 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. Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.Duties as assigned.Essential Qualifications Current Licensed Practical Nurse (LPN) 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.Must be detail oriented and have strong organizational and time management skills. Adaptive to a high pace and changing environment- flexibility in assignment.Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review. Proficient in MCG and CMS criteria setsExperience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred. Working knowledge of URAC and NCQA.2+ years’ experience in a UM team within managed care setting. 3+ years’ experience in clinical nurse setting preferred.TPA Experience preferred.
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FAQs About Utilization Management Nurse Jobs at Brighton Health Plan Solutions, LLC
What is the work location for this position at Brighton Health Plan Solutions, LLC?
This job at Brighton Health Plan Solutions, LLC is located in Chapel Hill, NC, according to the details provided by the employer. Some roles may also include multiple work locations depending on the requirement.
What pay range can candidates expect for this role at Brighton Health Plan Solutions, LLC?
Employer has not shared pay details for this role.
What employment applies to this position at Brighton Health Plan Solutions, LLC?
Brighton Health Plan Solutions, LLC lists this role as a Full-time position.
What experience level is required for this role at Brighton Health Plan Solutions, LLC?
Brighton Health Plan Solutions, LLC is looking for a candidate with "Senior-level" experience level.
Does Brighton Health Plan Solutions, LLC allow remote work for this role?
Yes, this position at Brighton Health Plan Solutions, LLC supports remote work, giving candidates the flexibility to work outside the primary office location.
What education level is required for this job?
The education requirement for this position is Nursing (RN, LPN). Candidates with relevant qualifications or equivalent experience may also be considered.
What benefits are offered by Brighton Health Plan Solutions, LLC for this role?
Brighton Health Plan Solutions, LLC offers Health Insurance for this position. Actual benefits may vary depending on the employer's policies and employment terms.
What is the process to apply for this position at Brighton Health Plan Solutions, LLC?
You can apply for this role at Brighton Health Plan Solutions, LLC either through Sonara's automated application system, which helps you submit applications 10X faster with minimal effort, or by applying manually using the direct link on the job page.