Utilization Management Nurse, Prior Authorization Specialist

5 days ago

SaintAubinsurGaillon, Normandie, United States Brighton Health Plan Solutions Full time
About the Role

Brighton Health Plan Solutions is seeking a skilled Utilization Management Nurse to join our team. As a Utilization Management Nurse, you will play a critical role in ensuring that our members receive the necessary care and services while minimizing unnecessary costs.

Key Responsibilities:

  • Perform prospective utilization reviews and first-level determinations for members using evidence-based guidelines, policies, and nationally recognized clinical criteria.
  • Identify potential Third-Party Liability and Coordination of Benefit Cases and notify appropriate parties/departments.
  • Collaborate with healthcare partners to ensure timely review of services and care.
  • Provide referrals to Case Management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
  • Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.

Requirements:

  • Current licensed LPN or Registered Nurse (RN) with state licensure.
  • Proficient in Microsoft Office (Outlook, Word, Excel, and PowerPoint).
  • Ability to work independently and adapt to a high-paced and changing environment.
  • Working knowledge of URAC and NCQA.
  • 2+ years of experience in a UM team within a managed care setting.

About Brighton Health Plan Solutions

We are a healthcare enablement company that partners with self-insured employers, Taft-Hartley Trusts, health systems, providers, and other TPAs to provide flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, proprietary provider networks, and innovative technology platforms.

Our Mission:

Transform the health plan experience by bringing outstanding products and services to our partners.

Our Vision:

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

Equal Opportunity Employer:

We are an equal opportunity employer and welcome diversity in the workplace.

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