Utilization Management Nurse
6 days ago
About The Role
Brighton Health Plan Solutions, LLC provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization is responsible for performing medical necessity reviews on prior authorization requests in accordance with national standards, contractual requirements, and a member's benefit coverage while working remotely.
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities and activities may change, or new ones may be assigned at any time with or without notice.
Primary Responsibilities
- Perform prospective utilization reviews and first level determinations for members using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
- Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
- Collaborates with healthcare partners to ensure timely review of services and care.
- Provides 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 and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
- Triage and prioritizes cases and other assigned duties to meet required turnaround times.
- Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements.
- Experience with outpatient reviews including DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
Essential Qualifications
- Current licensed LPN or Registered Nurse (RN) with state licensure. Must retain active and unrestricted licensure throughout employment.
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Must be able to work independently.
- Adaptive to a high pace and changing environment.
- Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
- Working knowledge of URAC and NCQA.
- 2+ years' experience in a UM team within managed care setting.
- 3+ years' experience in clinical nurse setting preferred.
- TPA Experience preferred.
About Brighton Health Plan Solutions, LLC
We are a healthcare enablement company that unlocks opportunities for our clients to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. We partner with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs to provide flexible and cutting-edge third-party administration services.
We are committed to increasing diversity, inclusion and a sense of belonging at every level. Our people are passionate about improving how healthcare is accessed and delivered. We encourage all team members to bring their authentic selves to work with all of their unique abilities.
We are an Equal Opportunity Employer.
Annual Salary Range: $60,000 - $75,000
The salary range and/or hourly rate listed is a good faith determination that may be offered to a successful applicant for this position at the time of the posting of an advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable by law including but not limited to location, years of relevant experience, education, credentials, skills, budget and internal equity.
We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated on brighonthps.com Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com
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