Remote Utilization Review Nurse

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

Job summary

Brighton Health Plan Solutions, LLC is seeking an Utilization Management Nurse to perform medical necessity reviews remotely. Licensed LPN with strong MS Office skills will review clinical criteria, coordinate with care partners, and document determinations in compliance with standards.

Two or more years in a UM team within managed care is preferred, as is nurse experience in clinical settings; TPA experience is a plus.

Qualifications

• Current Licensed Practical Nurse (LPN) with active state licensure.
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint).
• Must be able to work independently and manage time effectively.
• 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.

Responsibilities

• Performs clinical utilization reviews 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.
• Develops and reviews member centered documentation reflecting determinations in compliance with regulatory standards.
• Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
• Triages and prioritizes cases to meet turnaround times.
• Prepares and presents cases to Medical Director for oversight and determinations.
• Communicates determinations to providers/members in compliance with regulatory requirements.

Education

LPN license

Tools

Microsoft Office

Job description

Brighton Health Plan Solutions, LLC is seeking an Utilization Management Nurse to perform medical necessity reviews remotely. Licensed LPN with strong MS Office skills will review clinical criteria, coordinate with care partners, and document determinations in compliance with standards.

Two or more years in a UM team within managed care is preferred, as is nurse experience in clinical settings; TPA experience is a plus.