- Conduct prospective, concurrent, and retrospective utilization reviews applying evidence-based guidelines and clinical criteria.
- Identify potential Third-Party Liability and Coordination of Benefit Cases.
- Ensure appropriate discharge planning and determine post-acute needs.
- Provide referrals to various departments as necessary.
- Develop member-centered documentation in compliance with standards.
- Triage and prioritize cases to meet turnaround times.
- Present cases to Medical Director for oversight.
- Experience with outpatient reviews preferred.
- Current RN or LPN with state licensure.
- Proficiency in Microsoft Office.
- Ability to work independently in a fast-paced environment.
- Proficient in Utilization Review process.
- Knowledge of URAC and NCQA.
- 3+ years in UM team in managed care setting.
- TPA Experience preferred.
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Utilization Management Nurse - Carolina, United States - Brighton Health Plan Solutions, LLC
Description
Job Description
About The Role
BHPS offers Utilization Management services to clients. The Utilization Management Nurse conducts daily medical necessity reviews while operating remotely.
Primary Responsibilities
Essential Qualifications
Company Mission:
Our mission is to transform the health plan experience by providing top-notch products and services to partners.
Company Vision:
We aim to redefine health care quality and value through innovative partnerships.
DEI Purpose Statement
At BHPS, we value diversity, inclusion, and belonging in the workplace. We are dedicated to creating a culture that embraces differences at every level. We are an Equal Opportunity Employer.
