Utilization Review Nurse, Quality
3 weeks ago
BHPS provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical quality oversite. This position reports to the Clinical Program Manager.
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities and activities may change, or new ones may be assigned at any time with or without notice.
Primary Responsibilities
- Review and analyze denials of initial preservice medical necessity denials using nationally recognized clinical criteria and internal policies/procedures.
- Identify case issues, assist in developing quality initiatives and policy development
- Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments
- Support clinical quality audit oversight ensuring strict adherence of the UM process from end to end including intake, medical policy criteria selection, application, and case closure
- 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 Directors (internal and external IROs) for timely and accurate decisions
- Experience with multiple clinical settings/levels of care including but not limited to: Inpatient Acute, Step Down Post Acute (SNF/LTAC/ARU), Outpatient, DME, and Complex Care Needs
- Current licensed Registered Nurse (RN) with state licensure. Must retain active and unrestricted licensure throughout employment
- Understanding of Appeals guidelines as applicable with URAC, NCQA, and ERISA
- 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.
- 2+ years’ experience in a UM team/Appeals within managed care setting.
- 3+ years’ experience in clinical nurse setting preferred
- Grievance experience preferred
- TPA experience preferred.
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.
DEI Purpose Statement
At BHPS, we encourage all team members to bring your authentic selves to work with all of your unique abilities. We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace. We are building, nurturing and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.
- We are an Equal Opportunity Employer
Powered by JazzHR
PGw7e6XAgK
-
Utilization Review Nurse, Quality
1 week ago
Chapel Hill, North Carolina, United States Brighton Health Plan Solutions, LLC Full timeJob DescriptionJob DescriptionAbout The RoleBHPS provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical quality oversite. This position reports to the Clinical Program Manager.This job description is not designed to cover or contain a comprehensive listing of activities, duties...
-
Utilization Review Nurse, Quality
4 weeks ago
Chapel Hill, United States Brighton Health Plan Solutions, LLC Full timeJob DescriptionJob DescriptionAbout The RoleBHPS provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical quality oversite. This position reports to the Clinical Program Manager.This job description is not designed to cover or contain a comprehensive listing of activities, duties...
-
Utilization Review Nurse, Quality
3 weeks ago
Chapel Hill, United States Brighton Health Plan Solutions, LLC Full timeJob DescriptionJob DescriptionAbout The RoleBHPS provides Utilization Management services to its clients. The Utilization Review Appeals Nurse performs daily appeal reviews and clinical quality oversite. This position reports to the Clinical Program Manager.This job description is not designed to cover or contain a comprehensive listing of activities, duties...
-
Utilization Management Nurse, Concurrent Review
3 weeks ago
Chapel Hill, United States Brighton Health Plan Solutions Full timeAbout The Role BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs daily medical necessity reviews. This position reports to the Director, Clinical Programs. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities and activities may change,...
-
Utilization Management Nurse, Concurrent Review
3 weeks ago
Chapel Hill, United States Brighton Health Plan Solutions Full timeAbout The Role BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs daily medical necessity reviews. This position reports to the Director, Clinical Programs. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities and activities may change,...
-
Utilization Management Nurse, Concurrent Review
4 weeks ago
Chapel Hill, United States Brighton Health Plan Solutions, LLC Full timeJob DescriptionJob DescriptionAbout The RoleBHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs daily medical necessity reviews. This position reports to the Director, Clinical Programs.This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities...
-
Utilization Management Nurse, Concurrent Review
3 weeks ago
Chapel Hill, United States Brighton Health Plan Solutions, LLC Full timeJob DescriptionJob DescriptionAbout The RoleBHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs daily medical necessity reviews. This position reports to the Director, Clinical Programs.This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities...
-
Utilization Review Specialist
2 months ago
Wesley Chapel, United States Acadia Healthcare Inc. Full timeOverview Shift: 7am - 3:30pm PURPOSE STATEMENT: Proactively monitor utilization of services for patients to optimize reimbursement for the facility. Responsibilities ESSENTIAL FUNCTIONS: * Act as liaison between managed care organizations and the facility professional clinical staff. * Conduct reviews, in accordance with certification requirements, of...
-
Utilization Review Specialist
3 weeks ago
Wesley Chapel, United States Acadia Healthcare Inc. Full timeOverview Shift: 7am - 3:30pm PURPOSE STATEMENT: Proactively monitor utilization of services for patients to optimize reimbursement for the facility. Responsibilities ESSENTIAL FUNCTIONS: * Act as liaison between managed care organizations and the facility professional clinical staff. * Conduct reviews, in accordance with certification requirements, of...
-
Utilization Review Specialist
2 months ago
Wesley Chapel, United States Acadia Healthcare Full timeShift: 7am - 3:30pm PURPOSE STATEMENT:Proactively monitor utilization of services for patients to optimize reimbursement for the facility.ESSENTIAL FUNCTIONS:Act as liaison between managed care organizations and the facility professional clinical staff.Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care...
-
Utilization Review Specialist
3 weeks ago
Wesley Chapel, United States Acadia Healthcare Full timeShift: 7am - 3:30pm PURPOSE STATEMENT:Proactively monitor utilization of services for patients to optimize reimbursement for the facility.ESSENTIAL FUNCTIONS:Act as liaison between managed care organizations and the facility professional clinical staff.Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care...
-
Travel Nurse RN
2 weeks ago
Chapel Hill, United States Medical Solutions Full timeJob DescriptionMedical Solutions is seeking a travel nurse RN Case Manager, Utilization Review for a travel nursing job in Chapel Hill, North Carolina.Job Description & RequirementsSpecialty: Utilization ReviewDiscipline: RNDuration: 13 weeks40 hours per weekShift: 10 hours, daysEmployment Type: Travel We’re seeking talented healthcare professionals whose...
-
Chapel Hill, United States Brighton Health Plan Solutions, LLC Full timeJob DescriptionJob DescriptionAbout The RoleBHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews on prior authorization requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.This job...
-
Chapel Hill, United States Brighton Health Plan Solutions, LLC Full timeJob DescriptionJob DescriptionAbout The RoleBHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews on prior authorization requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.This job...
-
Chapel Hill, United States Brighton Health Plan Solutions Full timeAbout The RoleBHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews on prior authorization requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.This job description is not designed to...
-
Chapel Hill, United States Brighton Health Plan Solutions Full timeAbout The RoleBHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews on prior authorization requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.This job description is not designed to...
-
RN Utilization Manager
3 weeks ago
Chapel Hill, United States UNC Health Care Full timeDescription Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve. RN Utilization Manager position specifically for a Utilization Manager/Clinical Appeals Nurse. This person is based at the Hedrick building and is 100% on-site. This individual...
-
RN Utilization Manager
3 weeks ago
Chapel Hill, United States UNC Health Care Full timeDescription Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve. RN Utilization Manager position specifically for a Utilization Manager/Clinical Appeals Nurse. This person is based at the Hedrick building and is 100% on-site. This individual...
-
RN Utilization Manager
2 days ago
Chapel Hill, United States UNC Health Care Full timeDescription Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve. RN Utilization Manager position specifically for a Utilization Manager/Clinical Appeals Nurse. This person is based at the Hedrick building and is 100% on-site. This individual...
-
RN Utilization Manager
22 hours ago
Chapel Hill, United States UNC Health Full timeBecome part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve. RN Utilization Manager responsible for clinical reviews for medical necessity for initial review, admission and continuing stay reviews during the shift thereby decreasing risk of insurer...
