utilization management manager

Brighton Health Plan Solutions

<div>
 
 About The Role
 
 
 
 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&rsquo;s benefit coverage while working remotely.
 
 
 
 Primary Responsibilities
 
 
 
 <ul>
 <li>
 Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures
 </li>
 <li>
 Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments
 </li>
 <li>
 Collaborates with healthcare partners to ensure timely review of services and care
 </li>
 <li>
 Provides referrals to Case management, Disease Management, Appeals &amp; Grievances, and Quality Departments as needed
 </li>
 <li>
 Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
 </li>
 <li>
 Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate
 </li>
 <li>
 Triages and prioritizes cases and other assigned duties to meet required turnaround times
 </li>
 <li>
 Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations
 </li>
 <li>
 Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements
 </li>
 <li>
 Duties as assigned
 
 
 </li>
 </ul>
 
 Essential Qualifications
 
 
 
 <ul>
 <li>
 Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment
 </li>
 <li>
 Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
 </li>
 <li>
 Must be able to work independently
 </li>
 <li>
 Must be detail oriented and have strong organizational and time management skills
 </li>
 <li>
 Adaptive to a high pace and changing environment- flexibility in assignment
 </li>
 <li>
 Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
 </li>
 <li>
 Proficient in MCG and CMS criteria sets
 </li>
 <li>
 Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred
 </li>
 <li>
 Working knowledge of URAC and NCQA
 </li>
 <li>
 2+ years&rsquo; experience in a UM team within managed care setting
 </li>
 <li>
 3+ years&rsquo; experience in clinical nurse setting preferred
 </li>
 <li>
 TPA Experience preferred
 
 
 </li>
 </ul>
 
 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&rsquo;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&rsquo;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&rsquo;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&rsquo;s challenges into tomorrow&rsquo;s solutions.
 
 
 Come be a part of the Brightest Ideas in Healthcare&trade;.
 
 
 
 Company Mission
 
 
 
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; 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.
 
 
 Powered by JazzHR
 
 
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</div>

Utilization Management Nurse

Physicians Data Trust

<div><ul><li>Primary Purpose</li></ul>
To provide high-level customer service to PDTs&rsquo; clients with accuracy.<ul><li>
Principal Duties and Responsibilities - *Goals on Performance Review</li></ul><ul><li>
Answer calls from members, providers, and health plans regarding specific claim issues. Route and redirect calls as necessary.</li><li><ul><li>Return calls from the UM voicemail box within 24 hours</li><li>Perform timely follow-up on calls requiring research and call back within 24 hours.</li></ul></li><li>
Accurately interpret DOFRs &ndash; Division of Financial Responsibility documents to determine where specific health care services are rendered.</li><li>
Verify eligibility &amp; benefits for each submitted physician referral by contacting health plans for pertinent information.</li><li>
Work with contracting personnel to ensure the utilization of appropriate providers.</li><li><ul><li>Provide requested referral and network information to providers/staff promptly within 24 hours.</li></ul></li><li>
Use MedMC to log incoming calls and their resolution.</li><li>
Complete other projects as assigned by the supervisor</li><li>
Job Specifications (KSAs):<ul><li>
Requires the ability to speak, read, write, and understand English and other general educational skills, as is generally obtained by completing high school or a GED.</li><li>
Knowledge of the health or managed care industry is generally obtained through 1-2 years of work experience.</li><li>
Excellent communication skills with a focus on superior telephone etiquette.</li><li>
1-2 years of customer service experience required.</li></ul></li></ul>
 IV Position Performance Criteria<ul><li>
Ability to organize and maintain multiple sets of information and data.</li><li>
Consistently produces accurate and timely work as it relates to departmental goals.</li><li>
Demonstrates high reliability through consistent punctuality and attendance.</li><li>
Competently performs position requirements with minimal supervision and direction, including taking initiative and assuming responsibility for follow-through.</li><li>
Uses sound judgment regarding time management and prioritization of work to balance multiple tasks and meet required timeframes for all administrative activities as required.</li><li>
Demonstrates excellent interpersonal skills as discerned through observation and team project successes.</li><li>
Accurately interprets and applies departmental policies and procedures using sound judgment.</li><li>
Communicates professionally and respectfully with peers, superiors, subordinates, and clients.</li><li>
Provides constructive feedback on assigned work projects.</li><li>
Demonstrates overall professionalism in attitude, demeanor, and personal appearance.</li></ul></div>

Utilization Management Customer Service

Elevance Health

<div>Job ID:JP00046432
Anticipated Start Date: 05/13/2026
Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.
Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
Responsible for coordinating cases for precertification and prior authorization review.
Primary duties may include, but are not limited to:<ul><li>
Managing incoming calls or incoming post services claims work.
</li><li>Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.</li><li>
Refers cases requiring clinical review to a Nurse reviewer.
</li><li>Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.</li><li>
Responds to telephone and written inquiries from clients, providers and in-house departments.
</li><li>Conducts clinical screening process.
</li><li>Authorizes initial set of sessions to provider.
</li><li>Checks benefits for facility based treatment.
</li><li>Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.</li></ul>
Requirements:<ul><li>
Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.
</li><li>Associates will need to review service details and enter the authorization in our system and electronically send a confirmation letter to the provider. Associates will need to review our fax queues and pend a line in our UM system.</li><li>
Medical terminology training and experience in medical or insurance field preferred.
</li><li>Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.</li></ul>
Job Type: Contract Opportunity only
Additional Details:<ul><li>
100% remote.
</li><li>Monday - Friday 8 AM-5 PM EST. - NO OVERTIME / NO WEEKEND</li></ul> 
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. 
About BCForward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally. 
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work. 
BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability. 
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process. 
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.
<div>Pay Rate Range
13.12 - 23.8 USD hourly
</div><div>Additional Notes
The pay range is the range BCForward in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.
</div><div>Benefits Information
BCForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).</div></div>

Utilization Management Rep I (contract)

<div>Job ID:JP00046432
Anticipated Start Date: 05/13/2026
Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.
Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
Responsible for coordinating cases for precertification and prior authorization review.
Primary duties may include, but are not limited to:<ul><li>
Managing incoming calls or incoming post services claims work.
</li><li>Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.</li><li>
Refers cases requiring clinical review to a Nurse reviewer.
</li><li>Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.</li><li>
Responds to telephone and written inquiries from clients, providers and in-house departments.
</li><li>Conducts clinical screening process.
</li><li>Authorizes initial set of sessions to provider.
</li><li>Checks benefits for facility based treatment.
</li><li>Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.</li></ul>
Requirements:<ul><li>
Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.
</li><li>Associates will need to review service details and enter the authorization in our system and electronically send a confirmation letter to the provider. Associates will need to review our fax queues and pend a line in our UM system.</li><li>
Medical terminology training and experience in medical or insurance field preferred.
</li><li>Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.</li></ul>
Job Type: Contract Opportunity only
Additional Details:<ul><li>
100% remote.
</li><li>Monday - Friday 8 AM-5 PM EST. - NO OVERTIME / NO WEEKEND</li></ul>
.Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. 
About BCForward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally. 
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work. 
BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability. 
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process. 
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.
<div>Pay Rate Range
13.12 - 23.8 USD hourly
</div><div>Additional Notes
The pay range is the range BCForward in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.
</div><div>Benefits Information
CForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).</div></div>

<div>Job ID:JP00046432
Anticipated Start Date: 05/13/2026
Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.
Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
Responsible for coordinating cases for precertification and prior authorization review.
Primary duties may include, but are not limited to:<ul><li>
Managing incoming calls or incoming post services claims work.
</li><li>Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.</li><li>
Refers cases requiring clinical review to a Nurse reviewer.
</li><li>Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.</li><li>
Responds to telephone and written inquiries from clients, providers and in-house departments.
</li><li>Conducts clinical screening process.
</li><li>Authorizes initial set of sessions to provider.
</li><li>Checks benefits for facility based treatment.
</li><li>Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.</li></ul>
Requirements:<ul><li>
Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.
</li><li>Associates will need to review service details and enter the authorization in our system and electronically send a confirmation letter to the provider. Associates will need to review our fax queues and pend a line in our UM system.</li><li>
Medical terminology training and experience in medical or insurance field preferred.
</li><li>Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.</li></ul>
Job Type: Contract Opportunity only
Additional Details:<ul><li>
100% remote.
</li><li>Monday - Friday 8 AM-5 PM EST. - NO OVERTIME / NO WEEKEND</li></ul>
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
About BCForward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.
BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration. employed
<div>Benefits Information
BCForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).</div></div>

<div><h2 class="jobSectionHeader">Description</h2>
Job ID:JP00046432 
Anticipated Start Date: 05/13/2026
Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date. 
Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. 
Responsible for coordinating cases for precertification and prior authorization review. 
Primary duties may include, but are not limited to:<ul><li>
Managing incoming calls or incoming post services claims work.</li><li>
Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.</li><li>
Refers cases requiring clinical review to a Nurse reviewer.</li><li>
Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.</li><li>
Responds to telephone and written inquiries from clients, providers and in-house departments.</li><li>
Conducts clinical screening process.</li><li>
Authorizes initial set of sessions to provider.</li><li>
Checks benefits for facility based treatment.</li><li>
Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.</li></ul>
Requirements:<ul><li>
Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.</li><li>
Associates will need to review service details and enter the authorization in our system and electronically send a confirmation letter to the provider. Associates will need to review our fax queues and pend a line in our UM system.</li><li>
Medical terminology training and experience in medical or insurance field preferred.</li><li>
Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.</li></ul> 
Job Type: Contract Opportunity only 
Additional Details:<ul><li>
100% remote.</li><li>
Monday - Friday 8 AM-5 PM EST. - NO OVERTIME / NO WEEKEND</li></ul> 
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. 
About BCForward:
Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally. 
BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work. 
BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability. 
To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process. 
This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.
<div>Pay Rate Range
13.12 - 23.8 USD hourly
</div><div>Additional Notes
The pay range is the range BCForward in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.
</div><div>Benefits Information
BCForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.
The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).</div></div>

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