Utilization Management Nurse

Brighton Health Plan Solutions, LLC; Chapel Hill (NC); Remote; USD 65,000 - 80,000; Full time

Job summary

Brighton Health Plan Solutions, LLC is seeking an experienced Utilization Management Nurse (LPN) to perform medical necessity and benefit reviews remotely in North Carolina. You will use evidence-based guidelines and internal criteria to determine coverage and communicate decisions to providers and members.

Qualified candidates hold an active LPN license, have 2+ years in UM within managed care, and are proficient with Microsoft Office.

Qualifications

• Active LPN licensure in state with no restrictions.
• Experience with URAC and NCQA knowledge.
• Experience with utilization review processes and clinical criteria.
• 2+ years UM experience in managed care.
• 3+ years 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.
• 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.

Skills

Attention to detail

Time management

Independent work

Organizational skills

Communication skills

Education

LPN license

Tools

Microsoft Office

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 members 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.