Utilization Management Nurse

🔥 3 minutes ago

🌵 Arizona, Connecticut, +12 more states – Remote

🌵 Arizona – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🏈 Ohio – Remote 🦀 Maryland – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Brighton Health Plan Solutions

WebsiteLinkedInAll Job Openings

201 - 500 employees

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

Brighton Health Plan Solutions is a healthcare enablement company transforming the healthcare landscape through innovative technology and customized health plans. With over 30 years of experience in third-party administration, the company specializes in health plan management, direct contracting for employers, and integrated ancillary benefits. Brighton Health Plan Solutions provides advanced technology platforms to simplify administrative tasks and enhance member engagement. They serve as a crucial link in direct contracting between groups and health systems, providing administrative and provider contracting expertise. By aligning stakeholders and creating flexible health plan products, they strive to improve healthcare delivery and outcomes.

📋 Description

• 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.

🎯 Requirements

• 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.

🏖️ Benefits

• Health insurance • 401(k) matching • Flexible work hours • Paid time off