Remote Utilization Nurse — Evidence-Based Care Reviews

Brighton Health Plan Solutions; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

Brighton Health Plan Solutions is seeking a licensed RN for remote Utilization Management to review medical necessity and benefits for diverse client populations, applying evidence-based guidelines and national criteria.

The role requires independent work, strong organization, and timely case reviews. You will collaborate with healthcare partners, document determinations, and communicate results to providers and members in compliance with URAC and NCQA standards.

Qualifications

• RN with active state licensure.
• Proficient in Microsoft Office and data/documentation tools.
• Independent worker with strong organizational skills.
• Detail-oriented with time management skills.
• Adaptable to a fast-paced environment and changing assignments.
• Proficient in Utilization Review processes and contract language.
• Familiar with MCG and CMS criteria sets.
• Experience in both inpatient and outpatient reviews is preferred.
• 2+ years in UM within managed care; 3+ years in clinical nursing preferred.

Responsibilities

• Performs clinical utilization reviews using evidence-based guidelines, policies, and nationally recognized clinical criteria.
• Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate parties.
• 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 in compliance with regulatory standards.
• Identifies potential quality of care issues and intervenes as clinically appropriate.
• Triages and prioritizes cases to meet turnaround times.
• Prepares and presents cases to the Medical Director for oversight and determinations.
• Communicates determinations to providers and/or members in compliance with requirements.

Skills

MS Office proficiency

Independent worker

Detail-oriented

Time management

Adaptable to fast-paced environment

Utilization Review knowledge

MCG/CMS criteria knowledge

Inpatient/outpatient review experience

Education

RN with active state licensure

Tools

MCG criteria

CMS criteria

Microsoft Office

Job description

Brighton Health Plan Solutions is seeking a licensed RN for remote Utilization Management to review medical necessity and benefits for diverse client populations, applying evidence-based guidelines and national criteria.

The role requires independent work, strong organization, and timely case reviews. You will collaborate with healthcare partners, document determinations, and communicate results to providers and members in compliance with URAC and NCQA standards.