Medical Utilization Management Nurse

At Brighton Health Plan Solutions (BHPS), we’re creating something new and different in health care, and we’d love for you to be part of it. Based in New York City, BHPS is a rapidly growing, entrepreneurial health care enablement company bringing tangible innovation to the health care delivery system. Our team is committed to transforming how health care is accessed and delivered. We believe that cost, quality, and population health are optimized when people have long term relationships with their health care providers – and that’s why we’re creating new products that today do not exist anywhere in the New York/New Jersey market. With a growing labor business under the well-known MagnaCare brand, the launch of Create - a new marketplace of health systems focused on self-insured commercial health plan sponsors, and a successful Casualty business, we’re fiercely committed to positively impacting our partners.

BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.

Performs clinical utilization reviews 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 Identifies potential quality of care issues, service or treatment delays and intervenes 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. Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements. Duties as assigned.