About The Role BHPS provides Utilization Management services to its clients. The Utilization Management Nurse - Prior Authorization performs medical necessity reviews on prior authorization requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely. 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 utilization reviews and first level determinations 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. •    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 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 outpatient reviews including DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred. Essential Qualifications •    Current licensed LPN or Registered Nurse (RN) with state licensure. Must retain active and unrestricted 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. •   2+ years’ experience in a UM team within managed care setting. •   3+ 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 Annual Salary Range: $60,000 - $75,000 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. JOB ALERT FRAUD:  We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information.  Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section.  If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com Powered by JazzHR