Remote Utilization Management Nurse – Clinical Review Expert

Brighton Health Plan Solutions; Chapel Hill (NC); Remote; USD 65,000 - 90,000; Full time

Job summary

Brighton Health Plan Solutions is seeking an experienced Utilization Management Nurse to perform medical necessity and benefit reviews remotely, supporting both inpatient and outpatient cases. The role requires an active LPN license, strong organization, and proficiency with URAC/NCQA criteria, working independently in a fast-paced managed care setting.

Responsibilities include coordinating reviews, presenting cases to the Medical Director, and communicating determinations to providers and

Qualifications

• Active LPN license in good standing.
• Proficient in URAC and NCQA knowledge.
• 2+ years experience in a UM team within managed care.
• 3+ years experience in clinical nurse setting preferred.

Responsibilities

• Performs clinical utilization reviews using evidenced based guidelines and internal policies.
• Identifies potential Third-Party Liability and coordinates reviews.
• Collaborates with healthcare partners to ensure timely service review.
• Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality.
• Maintains case documentation reflecting regulatory and accreditation standards.
• Identifies quality of care issues and flags delays for clinical intervention.
• Triages cases to meet required turnaround times.
• Prepares and presents cases to Medical Director for determinations.
• Communicates determinations to providers and members per regulations.
• Fulfills other duties as assigned.

Skills

Independent worker

Detail oriented

Time management

Adaptability

Strong organizational skills

Education

Licensed Practical Nurse (LPN) license

Tools

Microsoft Office

Job description

Brighton Health Plan Solutions is seeking an experienced Utilization Management Nurse to perform medical necessity and benefit reviews remotely, supporting both inpatient and outpatient cases. The role requires an active LPN license, strong organization, and proficiency with URAC/NCQA criteria, working independently in a fast-paced managed care setting.

Responsibilities include coordinating reviews, presenting cases to the Medical Director, and communicating determinations to providers and