Brighton Health Plan Solutions

Utilization Review Nurse - Complex Care

Posted on

July 27, 2025

Job Type

Full-Time

Role Type

Utilization Review

License

RN

State License

New York

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Company Description

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™.

Job Description

Utilization Review Nurse, Complex Care Brighton Health Plan Solutions REMOTE – 100% FULL TIME

Requirements

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.

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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.

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