Utilization Management Nurse

Utilization Management Nurse

Brighton Health Plan Solutions

REMOTE 100%

FULL TIME

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