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Nurse Specialist in Utilization Management
2 months ago
Position Overview
Brighton Health Plan Solutions is seeking a dedicated Utilization Management Nurse specializing in Prior Authorization. This role involves conducting medical necessity evaluations on prior authorization submissions, ensuring compliance with national standards, contractual obligations, and member benefit coverage while working remotely.
Key Responsibilities
- Conduct prospective utilization assessments and initial determinations for members, utilizing evidence-based guidelines, established policies, and recognized clinical criteria.
- Identify potential Third-Party Liability and Coordination of Benefits cases, notifying relevant departments as necessary.
- Collaborate with healthcare providers to facilitate timely reviews of services and care.
- Refer cases to Case Management, Disease Management, Appeals & Grievances, and Quality Departments as required.
- Develop and review member-focused documentation and correspondence that reflect determinations in accordance with regulatory and accreditation standards, while identifying potential quality of care issues.
- Prioritize and manage cases and other assigned responsibilities to meet required turnaround times.
- Prepare and present cases to the Medical Director for oversight and necessity determinations, communicating outcomes to providers and/or members in compliance with regulations.
- Experience with outpatient reviews, including Durable Medical Equipment (DME), Genetic Testing, Clinical Trials, Oncology, and elective surgical cases is preferred.
Essential Qualifications
- Current licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN) with active and unrestricted state licensure.
- Proficiency in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint).
- Ability to work independently and adapt to a fast-paced, changing environment.
- Strong understanding of the Utilization Review process, including benefit interpretation and medical policy review.
- Familiarity with URAC and NCQA standards.
- Minimum of 2 years of experience in a Utilization Management team within a managed care setting.
- Preferred: 3+ years of experience in a clinical nursing environment and experience with Third-Party Administrators (TPA).
About Brighton Health Plan Solutions
At Brighton Health Plan Solutions, we are committed to enhancing how healthcare is accessed and delivered. Our culture promotes diversity, inclusion, and a sense of belonging at every level. We partner with self-insured employers, health systems, and other TPAs to address the challenges of modern healthcare through innovative third-party administration services.
Company Mission
To transform the health plan experience by providing exceptional products and services to our partners.
Company Vision
To redefine healthcare quality and value by aligning the incentives of our partners in impactful and innovative ways.
Diversity, Equity, and Inclusion Statement
At Brighton Health Plan Solutions, we encourage all team members to bring their authentic selves to work. We are dedicated to fostering a culture that embraces diversity, inclusion, and belonging.
