Remote Utilization Management Nurse – Clinical Reviews

Brighton Health Plan Solutions; Chapel Hill (NC); Remote; USD 70,000 - 95,000; Full time

Job summary

Brighton Health Plan Solutions is seeking an experienced Utilization Management Nurse to perform medical necessity and benefit reviews for clients while working remotely in a fast-paced environment. The role requires current LPN licensure and strong knowledge of URAC and NCQA standards.

Responsibilities include conducting reviews with evidenced-based guidelines, coordinating with healthcare partners, and providing timely determinations to providers and members.

Qualifications

• Current LPN with active, unrestricted state licensure.
• Proficient in Microsoft Office (Outlook, Word, Excel, PowerPoint).
• Ability to work independently and manage time effectively.
• Detail oriented with strong organizational skills.
• Adaptive to a fast-paced, changing environment.
• Proficient in utilization review processes and interpreting contracts.
• Familiar with MCG and CMS criteria sets.
• Experience in inpatient and outpatient reviews across BH, DME, genetics, trials.
• URAC and NCQA knowledge.
• 2+ years UM team experience; 3+ years clinical nurse setting preferred.

Responsibilities

• Performs clinical utilization reviews using evidenced-based guidelines and criteria.
• Identifies potential Third-Party Liability and Coordination of Benefit cases.
• 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.
• Develops and reviews member-centered documentation reflecting determinations per regulatory standards.
• Identifies quality of care issues and intervenes as clinically appropriate.
• Triages and prioritizes cases to meet turnaround times.
• Prepares and presents cases to Medical Director for oversight and necessity determinations.
• Communicates determinations to providers and members per regulatory requirements.
• Duties as assigned.

Skills

Microsoft Office

Independent worker

Detail oriented

Time management

Adaptability

UM criteria

MCG/CMS criteria

LPN paperwork/credentialing

TPA experience

Education

LPN licensure (state)

Job description

Brighton Health Plan Solutions is seeking an experienced Utilization Management Nurse to perform medical necessity and benefit reviews for clients while working remotely in a fast-paced environment. The role requires current LPN licensure and strong knowledge of URAC and NCQA standards.

Responsibilities include conducting reviews with evidenced-based guidelines, coordinating with healthcare partners, and providing timely determinations to providers and members.