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Nurse Specialist in Utilization Management
2 months ago
Brighton Health Plan Solutions is seeking a dedicated Utilization Management Nurse specializing in Prior Authorization. This role involves conducting assessments of medical necessity for prior authorization requests, ensuring compliance with established national standards and contractual obligations while working remotely.
Key Responsibilities
- Execute prospective utilization assessments and initial determinations for members, utilizing evidence-based guidelines, policies, and recognized clinical criteria.
- Detect potential Third-Party Liability and Coordination of Benefit scenarios, notifying relevant departments.
- Collaborate with healthcare partners to facilitate timely service reviews and care coordination.
- Refer cases to Case Management, Disease Management, Appeals & Grievances, and Quality Departments as necessary.
- Develop and review member-focused documentation and correspondence that reflect determinations, ensuring compliance with regulatory and accreditation standards while identifying potential quality of care issues.
- Prioritize and manage cases to meet required turnaround times effectively.
- Prepare and present cases to the Medical Director for oversight and necessity determinations, communicating outcomes to providers and members in line with regulatory requirements.
- Experience with outpatient reviews, including Durable Medical Equipment (DME), Genetic Testing, Clinical Trials, Oncology, and elective surgical cases is preferred.
- Active LPN or RN license with state licensure, maintaining unrestricted licensure throughout employment.
- Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint).
- Ability to work independently and adapt to a fast-paced, changing environment.
- In-depth knowledge of the Utilization Review process, including benefit interpretation and medical policy review.
- Familiarity with URAC and NCQA standards.
- Minimum of 2 years' experience in a Utilization Management team within a managed care environment.
- Preferred 3+ years' experience in a clinical nursing setting.
- Experience with Third-Party Administrators (TPA) is advantageous.
At Brighton Health Plan Solutions, we are committed to enhancing the accessibility and delivery of healthcare. Our culture emphasizes diversity, respect, and inclusion, encouraging all team members to express their authentic selves and unique abilities.
We partner with self-insured employers, health systems, and other TPAs to address contemporary healthcare challenges through innovative third-party administration services. Our extensive experience in health plan management, combined with proprietary provider networks and advanced technology, enables us to offer customizable solutions that enhance member experiences and improve health outcomes.
Company Mission
To transform the health plan experience by delivering exceptional products and services to our partners.
Company Vision
To redefine healthcare quality and value by aligning our partners' incentives in innovative ways.
Diversity, Equity, and Inclusion Commitment
At Brighton Health Plan Solutions, we foster a culture that values diversity and inclusion, encouraging all team members to bring their authentic selves to work. We respect individual experiences and are dedicated to creating a workplace that embraces a sense of belonging for everyone.
