Concurrent Review Nurse
2 weeks ago
Brighton Health Plan Solutions (BHPS) offers comprehensive Utilization Management services to its clients. The Utilization Management Nurse is responsible for conducting daily assessments of medical necessity. This role reports directly to the Director of Clinical Programs.
This job description is intended to provide a general overview of the responsibilities and duties associated with this position. Responsibilities may evolve, or new tasks may be assigned as necessary.
Key Responsibilities
- Conducts concurrent utilization assessments (Acute, SNF, LTACH, ARF) and initial determination approvals for members, utilizing evidence-based guidelines, policies, and recognized clinical criteria.
- Identifies potential Third-Party Liability and Coordination of Benefit cases, notifying relevant departments.
- Facilitates discharge planning that aligns with the member's needs and acuity, determining post-acute requirements, including levels of care and necessary medical equipment.
- Refers cases to Case Management, Disease Management, and Quality Departments as required.
- Develops and reviews member-centered documentation and correspondence to ensure compliance with regulatory and accreditation standards, identifying potential quality of care issues.
- Prioritizes and manages cases and other assigned tasks to meet required turnaround times.
- Prepares and presents cases to the Medical Director for oversight and necessity determinations, communicating outcomes to providers and members in accordance with regulatory requirements.
- Provides insights to leadership on opportunities to enhance the appropriateness of care and medical necessity based on clinical guidelines.
- Reviews member transfer or discharge plans to ensure timely transitions between care levels and facilities.
- Active Registered Nurse (RN) license in good standing, with a commitment to maintaining licensure throughout employment.
- Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint).
- Ability to work independently and adapt to a fast-paced, dynamic environment.
- Expertise in the Utilization Review process, including benefit interpretation and policy review.
- Familiarity with URAC and NCQA standards.
- Minimum of 2 years of experience in a Utilization Management team within a managed care environment.
- Preferred: 3+ years of experience in a clinical nursing setting.
- Preferred: Experience with Third-Party Administrators (TPA).
At BHPS, our commitment lies in enhancing how healthcare is accessed and delivered. We foster a diverse and inclusive culture that encourages respect and belonging at every level. Our organization collaborates 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, proprietary provider networks, and advanced technology solutions enable us to offer customizable tools that enhance member experiences and improve health outcomes.
Join us in our mission to deliver the Brightest Ideas in HealthcareTM.
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 innovative ways.
DEI Purpose Statement
At BHPS, we invite all team members to bring their authentic selves to work, embracing the diversity of experiences and perspectives. We are dedicated to fostering a culture that promotes diversity, inclusion, and a sense of belonging at every level.
- We are an Equal Opportunity Employer.
-
Chapel Hill, North Carolina, United States Brighton Health Plan Solutions Full timeAbout The PositionBrighton Health Plan Solutions is dedicated to providing top-tier Utilization Management services. The Utilization Management Nurse is responsible for conducting daily assessments of medical necessity. This role reports directly to the Director of Clinical Programs.This job description is intended to outline the primary responsibilities and...
-
Chapel Hill, North Carolina, United States Brighton Health Plan Solutions Full timeAbout The RoleBrighton Health Plan Solutions (BHPS) is dedicated to delivering exceptional Utilization Management services. The Utilization Management Nurse is responsible for conducting daily assessments of medical necessity. This role reports directly to the Director of Clinical Programs.This job description is intended to outline the primary...
-
Chapel Hill, North Carolina, United States Brighton Health Plan Solutions, LLC Full timeJob OverviewPosition SummaryBrighton Health Plan Solutions, LLC is seeking a dedicated Utilization Management Nurse to provide essential services in the realm of healthcare management. This role is pivotal in conducting daily assessments of medical necessity and will report directly to the Director of Clinical Programs.Key ResponsibilitiesPerform utilization...
-
Chapel Hill, North Carolina, United States Brighton Health Plan Solutions, LLC Full timeJob SummaryWe are seeking a highly skilled Utilization Management Nurse to join our team at Brighton Health Plan Solutions, LLC. As a Utilization Management Nurse, you will play a critical role in ensuring that our members receive the most appropriate and cost-effective care.Key ResponsibilitiesConduct daily medical necessity reviews to determine the...
-
Nurse Specialist in Utilization Management
2 weeks ago
Chapel Hill, North Carolina, United States Brighton Health Plan Solutions Full timePosition OverviewBrighton 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 in alignment with established national guidelines, contractual obligations, and member benefit coverage while operating in a...
-
Nursing Assistant II + Clerical Specialist
2 weeks ago
Chapel Hill, North Carolina, United States UNC Health Full timeJob SummaryThe Clinical Support Technician II is a vital member of the Perioperative Preop Care Unit team at UNC Health. This role requires a skilled and detail-oriented individual to provide high-quality patient care and support to our patients and staff.Key ResponsibilitiesAssist physicians and other healthcare providers with routine examinations and...
-
Nurse Specialist in Utilization Management
2 weeks ago
Chapel Hill, North Carolina, United States Brighton Health Plan Solutions Full timePosition OverviewBrighton 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...
-
Nurse Specialist in Utilization Management
2 weeks ago
Chapel Hill, North Carolina, United States Brighton Health Plan Solutions Full timeAbout The PositionBrighton Health Plan Solutions is dedicated to providing exceptional Utilization Management services. The Utilization Management Nurse - Prior Authorization is responsible for conducting medical necessity evaluations on prior authorization submissions in line with national guidelines, contractual obligations, and member benefit coverage...
-
Travel Nurse RN
5 days ago
Chapel Hill, North Carolina, United States TravelNurseSource Full timeAbout the PositionWe are working with Host Healthcare to find a qualified Med/Surg RN for a travel nursing assignment in a reputable healthcare facility.Job SummaryThis is a travel nursing opportunity for a Registered Nurse - Medical-Surgical to work in a dynamic healthcare environment. As a travel nurse, you will have the opportunity to work in a new...
-
Traveling Operating Room Nurse
13 hours ago
Chapel Hill, North Carolina, United States Host Healthcare Full timeJob Title: Traveling Operating Room NurseJob Summary:Host Healthcare is seeking an experienced Operating Room Registered Nurse for an exciting travel nursing opportunity. As a travel nurse with Host Healthcare, you will have the opportunity to work in a dynamic and fast-paced environment, providing high-quality patient care and collaborating with a team of...
-
Nursing Assistant II + Clerical
2 days ago
Chapel Hill, North Carolina, United States UNC Health Care Full timeJob SummaryWe are seeking a highly skilled and dedicated Clinical Support Technician II to join our dynamic team at UNC Medical Center. This is a 36-hour per week position, working 12-hour rotating shifts with some flexibility, and with weekend and holiday rotation.Key ResponsibilitiesAssist physicians and other healthcare providers with routine examinations...
-
Travel Nurse Position
16 hours ago
Chapel Hill, North Carolina, United States Host Healthcare Full timeJob Summary:Host Healthcare is seeking an experienced Emergency Room Registered Nurse for a challenging and rewarding travel nursing assignment. As a valued member of our team, you will have the opportunity to work in a dynamic and fast-paced environment, providing high-quality patient care and contributing to the success of our healthcare organization.Key...
-
Travel Nurse Position
5 days ago
Chapel Hill, North Carolina, United States Host Healthcare Full timeJob Summary:Host Healthcare is seeking an experienced Emergency Room Registered Nurse for a challenging and rewarding travel nursing assignment. As a valued member of our team, you will have the opportunity to work in a dynamic and fast-paced environment, providing high-quality patient care and contributing to the success of our healthcare organization.Key...
-
Travel Nurse Position
5 days ago
Chapel Hill, North Carolina, United States Host Healthcare Full timeJob Summary:Host Healthcare is seeking an experienced Post Anesthesia Care Unit Registered Nurse to fill a challenging and rewarding Travel Nursing position. As a key member of our team, you will provide high-quality patient care in a fast-paced environment.Responsibilities:Deliver exceptional patient care in the Post Anesthesia Care Unit, ensuring a smooth...
-
Travel Nursing Opportunities
14 hours ago
Chapel Hill, North Carolina, United States Host Healthcare Full timeAbout Host HealthcareAt Host Healthcare, we are dedicated to empowering the life and healthcare career you deserve. As a nurse, allied, or therapy professional, you will be matched to one of our responsive recruiters who will have your back throughout your journey. You will also be connected with a full support team that was rated #1 in Nursing Satisfaction...
-
Traveling Operating Room Nurse Opportunity
4 days ago
Chapel Hill, North Carolina, United States Host Healthcare Full timeJob Title: Traveling Operating Room Nurse OpportunityJob Summary:Host Healthcare is seeking an experienced Operating Room Registered Nurse for an exciting travel nursing opportunity. As a travel nurse with Host Healthcare, you will have the opportunity to work in a dynamic and fast-paced environment, providing high-quality patient care and contributing to...
-
Nursing Assistant II + Clerical
1 month ago
Chapel Hill, North Carolina, United States UNC Health Care Full timeDescription This position qualifies for our Nursing Support Incentive Program - specifically for internal employees who are currently in a per diem status converting to full time (36+hrs/wk) status. The Nursing Support Incentive Program includes $5,000 paid over a three (3) year commitment. Learn more about the program here: The Ambulatory Surgical Center...
-
Nursing Assistant I + Clerical
2 months ago
Chapel Hill, North Carolina, 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. This position qualifies for our Nursing Support Incentive Program. The Nursing Support Incentive Program includes $5,000 paid over a three (3) year commitment. Learn more about...
-
Nursing Assistant I + Clerical
2 months ago
Chapel Hill, North Carolina, United States UNC Health Care Full timeDescription This position qualifies for our Nursing Support Incentive Program. The Nursing Support Incentive Program includes $5,000 paid over a three (3) year commitment. Learn more about the program here: Nursing Assistant I + Clerical (Clinical Support Tech I) needed for the Burn Center. Our 21 bed ICU capable Burn Center has the most state of the art...
-
Nurse Practitioner
23 hours ago
Chapel Hill, North Carolina, United States Wellstar Health System, Inc. Full timeJob SummaryThe Wellstar Health System, Inc. is seeking a highly skilled and compassionate Registered Nurse to join our team at Kennestone Hospital. As a RN Clinical Nurse, you will be a proactive member of an interdisciplinary team of licensed and unlicensed care givers who ensure that patients, families and significant others receive individualized high...
