Utilization Management Nurse, Prior Authorization

Brighton Health Plan Solutions; Chapel Hill (NC); Remote; USD 65,000 - 85,000; Full time

Job summary

Brighton Health Plan Solutions seeks a Utilization Management Nurse - Prior Authorization to perform medical necessity reviews and collaborate with healthcare partners. The role involves analyzing cases, ensuring compliance with standards, and working remotely. The ideal candidate will have RN/LPN licensure and experience in utilization review within managed care settings.

Qualifications

• At least 2 years’ experience in a UM team within a managed care setting.
• 3+ years’ experience in a clinical nurse setting preferred.

Responsibilities

• Perform medical necessity reviews based on clinical criteria and guidelines.
• Collaborate with healthcare partners for timely review and referrals.
• Prepare cases for Medical Director for oversight determinations.

Skills

Utilization Review process

Clinical assessment

Behavioral Health knowledge

Education

Current licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN)

Tools

Microsoft Office suite

Job description

About The Role

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

Primary Responsibilities

• Perform prospective utilization reviews and first-level determinations for members using evidenced-based guidelines, policies, and nationally recognized clinical criteria and internal policies/procedures.
• Identify potential Third-Party Liability and Coordination of Benefit Cases and notify appropriate parties/departments.
• Collaborate with healthcare partners to ensure timely review of services and care.
• Provide 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. Identify potential quality of care issues, service or treatment delays, and intervene as clinically appropriate.
• Triages and prioritizes cases and other duties to meet required turnaround times.
• Prepare and present cases to Medical Director for oversight and necessity determinations. Communicate determinations to providers and/or members in compliance with regulatory and accreditation requirements.
• Experience with outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and elective surgical cases is preferred.

Essential Qualifications

• Current licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) with active, unrestricted state licensure.
• Proficient in Microsoft Office suite (Outlook, Word, Excel, PowerPoint).
• Ability to work independently and adapt to a high-paced, changing environment.
• Proficient in Utilization Review process, including benefit interpretation, contract language, and medical/policy review.
• Working knowledge of URAC and NCQA standards.
• At least 2 years’ experience in a UM team within a managed care setting.
• 3+ years’ experience in a clinical nurse setting is preferred.
• TPA experience is a plus.

Company Mission

Transform the health plan experience by bringing outstanding products and services to our partners.

Company Vision

Redefine healthcare quality and value by aligning the incentives of our partners in powerful and unique ways.

DEI Purpose Statement

At BHPS, we encourage all team members to bring your authentic selves to work with your unique abilities. We respect your experiences and welcome you to contribute your full lived experience. We are committed to increasing diversity, inclusion, and a sense of belonging at every level.

We are an Equal Opportunity Employer.

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