Primary Responsibilities

Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members 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
Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning
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 and identify potential quality of care issues, service or treatment delays and intervenes or 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. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements
Experience with Complex Medical case reviews including but not limited to: Oncology, Clinical Trials, High Cost Medical Pharmacy and Transplants
Act as a resource for complex case discussions for all staff

Essential Qualifications

Current licensed Registered Nurse (RN) with state licensure. Must retain active licensure throughout employment
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Must be able to work independently
Adaptive to a high pace and changing environment
Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
Working knowledge of URAC and NCQA
3+ years’ experience in a UM team within managed care setting
5+ years experience in clinical nurse setting preferred
TPA Experience preferred

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

Brighton Health Plan Solutions

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