Utilization Management Nurse
Compensation
$0.07 – $0.07 /yr
Employment type
Full-time
Work setting
Remote
Location
Remote
Schedule
Day shift
Posted
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Job overview
Compensation is $0 per year. The Utilization Management Nurse role is fully remote; the listing location is Chapel Hill, NC. Brighton Health Plan Solutions provides utilization management services to its clients. The nurse reviews medical necessity and benefits against clinical criteria, policies, contracts, and member coverage. Timely, well-documented reviews and communication support appropriate care decisions and compliance with regulatory and accreditation requirements.
What you'll do
- Perform clinical utilization reviews using evidence-based guidelines and recognized criteria
- identify potential third-party liability and coordination-of-benefits cases
- collaborate with healthcare partners
- refer cases to appropriate departments
- document determinations
- identify quality-of-care issues and delays
- prioritize cases to meet turnaround times
- present cases to the Medical Director
- communicate determinations to providers or members.
What we're looking for
- Skills & competencies
- utilization management nurseremotechapel hill nc listing locationlicensed practical nursemedical necessity reviewutilization reviewmcg criteriacms criteriamanaged careclinical documentationbrighton health plan solutions
- Work arrangement
- Weekend coverage required
Why this role
Requires an active, unrestricted Licensed Practical Nurse license; experience with MCG and CMS criteria is required by the posting.
About the employer
Brighton Health Plan Solutions, LLC is hiring for this role. Industry: Direct Health and Medical Insurance Carriers. Sector: 52.
Additional details
- Industry sector
- 52
- Industry
- Direct Health and Medical Insurance Carriers
- Occupation code
- 29-2061.00
You'll be redirected to the employer's application page.
Listing ID: bfac56af-55dc-48d6-9d99-7e7053ac3a84