About The Role 

The Medical Utilization Management Nurse is responsible for medical necessity review of services that require prior authorization. The medical necessity review process includes assessment and interpretation of plan specific benefits, plan specific medical criteria, and clinical documentation. The position requires collaboration and communication with providers and members. In addition, the position requires collaboration within the clinical programs department and cross-functionally across the organization.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities and activities may change, or new ones may be assigned at any time with or without notice.

Primary Responsibilities 

• Perform prospective, concurrent, and retrospective utilization reviews using evidence based guidelines, policies and nationally recognized clinical criteria, and internal policies and procedures. 

• Case escalation for Medical Director (MD) review, when appropriate. 

• Prepare and present cases for MD oversight and medical necessity coverage determinations including communicating coverage determinations to providers and/or members in compliance with regulatory and accreditation requirements. 

• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.

• Ensure discharge (DC) planning at all levels of care are appropriate to meet the members needs including post-acute care needs to ensure quality and most cost effective care is established prior to discharge (i.e. post discharge services including durable medical equipment, home care needs etc.) 

• Identify potential quality of care issues, service or treatment delays, and intervene as clinically appropriate. 

• Provide referrals to Case Management, Disease Management, Appeals & Grievances, and Quality Departments, as appropriate. 

• Identify potential Third-Party Liability and Coordination of Benefit Cases, notify appropriate parties/departments. 

• Triage and prioritize cases and other assigned duties to meet turnaround times. 

• Other tasks and responsibilities as assigned.

Essential Qualifications 

• Current unrestricted licensed Registered Nurse (RN). Must retain active RN licensure throughout employment. 

• 3 years' experience functioning as a Utilization Management nurse within a managed care setting.

• Proficient in the Utilization Review process including but not limited to: benefit interpretation, contract language, medical and policy review, etc.

• Working knowledge of URAC and/or NCQA.

• Experience using clinical guidelines (Milliman (MCG) Guidelines and/or Interqual preferred). 

• Proficient in Microsoft Office (Outlook, Word, Excel, and PowerPoint) 

• Must be able to work independently. 

• Adaptive to a high pace and changing environment.

• Proficient written and verbal communication skills. 

Preferred Qualifications 

• 5 years RN experience in a clinical setting. 

• Experience with multiple clinical settings/levels of care including but not limited to: Acute Inpatient, Post Acute Step Down (SNF/LTAC/ARU), Outpatient, DME, etc. 

• Experience with complex case review including but not limited to: transplants, genetic testing, oncology, etc. 

• TPA Experience.

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care 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 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

Annual Salary Range: $70,000 - $85,000

The salary range and/or hourly rate listed is a good faith determination that may be offered to a successful applicant for this position at the time of the posting of an advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable by law including but not limited to location, years of relevant experience, education, credentials, skills, budget and internal equity.