Utilization Management Nurse

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

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.