Utilization Management Nurse

Brighton Health Plan Solutions; Chapel Hill (NC); Remoto; USD 65.000 - 90.000; Tempo pieno

Descrizione del lavoro

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

Competenze

• 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.

Mansioni

• 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.

Conoscenze

Independent worker

Detail oriented

Time management

Adaptability

Strong organizational skills

Formazione

Licensed Practical Nurse (LPN) license

Strumenti

Microsoft Office

Descrizione del lavoro

About The Role

BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.

About The Role

BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.

Primary 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.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
• Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
• Triages 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.
• Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
• Duties as assigned.

Essential Qualifications

• Current Licensed Practical Nurse (LPN) 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.
• Must be detail oriented and have strong organizational and time management skills.
• Adaptive to a high pace and changing environment- flexibility in assignment.
• Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
• Proficient in MCG and CMS criteria sets
• Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
• 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.