Medical Utilization Review Nurse Job at Brighton Health Plan Solutions, Chapel Hill, NC

cWYyN3lzMmx2aGx3bGxwQnh4dnNpTDVy
  • Brighton Health Plan Solutions
  • Chapel Hill, NC

Job Description

Utilization Management Nurse

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) or Registered Nurse (RN) with state licensure. Must retain active and unrestricted licensure throughout employment.
  • Weekend availability.
  • 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.

At Brighton Health Plan Solutions (BHPS), we're creating something new and different in health care, and we'd love for you to be part of it. Based in New York City, BHPS is a rapidly growing, entrepreneurial health care enablement company bringing tangible innovation to the health care delivery system. Our team is committed to transforming how health care is accessed and delivered. We believe that cost, quality, and population health are optimized when people have long term relationships with their health care providers and that's why we're creating new products that today do not exist anywhere in the New York/New Jersey market.

Transform the health plan experience how health care is accessed and delivered by bringing outstanding products and services to our partners. Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways. At BHPS, we encourage all team members to bring your authentic selves to work with all of your unique abilities. We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace. We are building, nurturing and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level. We are an Equal Opportunity Employer.

Job Tags

Contract work, Work at office, Remote work, Weekend work,

Similar Jobs

Superior Talent Source

Restaurant Service Manager | Great Culture Brand! Job at Superior Talent Source

 ...Job Description Job Description We are seeking a dedicated and motivated Restaurant Manager to help lead the team at a Casual Steakhouse. As the Restaurant Manager, you will play a vital role in supporting the restaurant's operations, delivering exceptional service... 

Medium

Work From Home - Bilingual Client Services Representative Job at Medium

 ...goal-oriented individuals with leadership potential to join our rapidly growing company. Preferred Qualifications Bilingual (Spanish and English) Excellent communication skills Leadership capabilities Self-starter Positive attitude Growth mindset... 

Bon Appetit

Sous Chef Job at Bon Appetit

 ...Job Description Job Description Position Title: Sous Chef Reports To: Salary: $60,000 to $68,000 Our Passion...  ...Reliable transportation is a must. Background in restaurants, hotels, corporate dining, education, military, health care, or related... 

Medium

Short-Form Video Content Creator & Scheduler (Overland Park) Job at Medium

 ...We are seeking a Short-Form Video Content Creator & Scheduler to produce engaging vertical video content for TikTok, Instagram Reels, Facebook Reels, and YouTube Shorts, and to schedule and publish content using Hootsuite according to a defined content calendar. This... 

SynergisticIT

Java/Full Stack Developer - Entry/Junior Level Job at SynergisticIT

Software Programmer Position At SynergisticIT, we're all about making connections. Whatever IT goals you have, our software programmers can help achieve those. Our software development teams can take up turnkey projects and execute them in an effective and efficient...