About The Role

• Review denied authorization cases within the Utilization Management system to understand the clinical determination and supporting rationale prior to letter creation or finalization.
• Draft, edit, and format denial and partial denial letters based on authorization determinations, including creation of member friendly letter language, accurately copying and inserting approved clinical statements, criteria citations, and other information into correspondence templates.
• Apply working knowledge of Utilization Management processes and sound judgment to ensure all written correspondence is clear, readable, complete, and accurate.
• Ensure all letter content, data fields, and member, provider, and service details are accurately populated to prevent compliance risks or downstream operational issues.
• Communicate with physicians and nursing staff as needed to clarify determinations, obtain missing information, or resolve discrepancies prior to letter release.
• Prioritize and triage denied authorization cases in alignment with client-specific requirements and regulatory turnaround times.
• Respond to and resolve member and provider inquiries related to denied authorizations and denial correspondence.
• Responsible for pulling and analyzing reporting around denial processes and presenting analysis to leadership.
• Perform other related duties as assigned.

• LPN license required.
• Two or more years of experience, in Utilization Management or medical necessity Appeals.
• Strong verbal and written communication skills.
• Demonstrated customer service skills, including effective written and verbal communication.
• Proficient in Microsoft Office applications, including Word, Excel, and Outlook, in a Windows-based environment.
• Ability to adapt quickly to changing business needs and learn new processes and systems

• Previous experience reviewing or writing UM denial letter language
• Proficient/Experienced with CPT4 and ICD-10 codes
• Working knowledge of URAC and NCQA documentation standards

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

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