Nurse Specialist in Utilization Management
2 weeks ago
Brighton 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 while operating remotely.
This job description is intended to outline the primary responsibilities and duties associated with this role; it is not exhaustive and may evolve over time as needed.
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 Benefit scenarios, notifying relevant departments.
- Engage with healthcare partners to ensure prompt review of services and care.
- Facilitate referrals to Case Management, Disease Management, Appeals & Grievances, and Quality Departments as necessary.
- Develop and assess member-focused documentation and correspondence that reflects determinations in compliance with regulatory and accreditation standards, while identifying potential quality of care issues and service delays.
- 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 accordance with regulatory and accreditation requirements.
- Experience with outpatient reviews including Durable Medical Equipment (DME), Genetic Testing, Clinical Trials, Oncology, and elective surgical cases is preferred.
- Current active LPN or Registered Nurse (RN) license with state licensure; must maintain active and unrestricted licensure throughout employment.
- Proficient in Microsoft Office Suite (Outlook, Word, Excel, and PowerPoint).
- Able to work independently and adapt to a fast-paced, dynamic 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' 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 a plus.
At Brighton Health Plan Solutions, we are committed to enhancing how healthcare is accessed and delivered. Our culture promotes diversity, respect, and inclusion at every level, encouraging team members to express their authentic selves and unique abilities.
As a partner to self-insured employers, Taft-Hartley Trusts, health systems, providers, and other TPAs, we address contemporary healthcare challenges through our innovative third-party administration services. Our extensive experience in health plan management, proprietary provider networks, and advanced technology platform enables us to provide clients with tailored solutions 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 outstanding products and services to our partners.
Company Vision
To redefine healthcare quality and value by aligning the incentives of our partners in unique and impactful ways.
Diversity, Equity, and Inclusion Commitment
At Brighton Health Plan Solutions, we encourage all team members to bring their authentic selves to work, respecting diverse experiences and fostering a culture that values inclusion and belonging at every level.
- We are an Equal Opportunity Employer.
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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...
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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...
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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...
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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...
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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...
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