Company: Brighton Health Plan Solutions, LLC

Job Title: Utilization Management Nurse, Quality & Appeals

Department: Utilization Management/Clinical Programs

About The Role

BHPS provides Utilization Management services to its clients. The Utilization Management Appeals Nurse performs daily appeal reviews and clinical quality oversite. This position reports to the Clinical Program Manager.

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.

Primary Responsibilities

• and analyze denials of initial preservice medical necessity denials using nationally recognized clinical criteria and internal policies/procedures.
• case issues, assist in developing quality initiatives and policy development.

Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.

Support clinical quality audit oversight ensuring strict adherence of the UM process from end to end including intake, medical policy criteria selection, application, and case closure.

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 Directors (internal and external IROs) for timely and accurate decisions.

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

Essential Qualifications

• licensed Registered Nurse (RN) with state licensure. Must retain active and unrestricted licensure throughout employment.
• of Appeals guidelines as applicable with URAC, NCQA, and ERISA.
• in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• be able to work independently.
• to a high pace and changing environment.
• in Utilization Review process including benefit interpretation, contract language, medical and policy review.
• years’ experience in a UM team/Appeals within managed care setting.
• years’ experience in clinical nurse setting preferred.
• experience preferred.
• experience preferred.

DEI Purpose Statement

At BHPS, we encourage all team members to bring your authentic selves to work with all 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.

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: [email protected].