utilization review specialist

BRADFORD HEALTH SERVICES

<div>About Company:
We&rsquo;re officially a Great Place To Work&reg;! We&rsquo;ve always believed that supporting our team is just as important as supporting our patients. Now, we&rsquo;re proud to share that we&rsquo;ve earned Great Place To Work&reg; Certification - based entirely on feedback from our own employees.
Read more here: https://ow.ly/YQ1C50WuRH1
This certification reflects the culture we&rsquo;ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.
At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.
Our benefits include:<ul><li>
Medical Coverage &ndash; Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.</li><li>
Expanded Coverage &ndash; Options for domestic partners and a wider network of in-network providers.</li><li>
Mental Health Support &ndash; Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.</li><li>
Voluntary Coverages &ndash; Pet insurance, home and auto insurance, family legal services, and more.</li><li>
Student Loan Repayment &ndash; Available for nurses and therapists.</li><li>
Retirement Benefits &ndash; 401(k) plan through Voya to help employees plan for the future.</li><li>
Generous PTO &ndash; A robust paid time off policy to support work-life balance.</li><li>
Voluntary Benefits for Part-Time Employees &ndash; Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.</li></ul>
At Bradford Health Services, we don&rsquo;t just invest in our patients&mdash;we invest in our people. 
About the Role:
The Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. The specialist collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care. Ultimately, the Utilization Review Specialist contributes to the integrity and sustainability of healthcare delivery systems across the United States.
Minimum Qualifications:<ul><li>
Bachelor&rsquo;s degree in a healthcare or related field.</li><li>
At least 2 years of experience in utilization review, case management, or clinical healthcare roles.</li><li>
Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.</li><li>
Familiarity with insurance authorization processes and healthcare reimbursement models.</li><li>
Excellent analytical, communication, and organizational skills.</li></ul>
Preferred Qualifications:<ul><li>
Experience with electronic health records (EHR) systems and utilization management software.</li><li>
Certification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager).</li><li>
Prior experience working with managed care organizations or insurance companies.</li><li>
Advanced knowledge of Medicare, Medicaid, and other payer-specific guidelines.</li></ul>
Responsibilities:<ul><li>
Review and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services.</li><li>
Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.</li><li>
Make informed decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements.</li><li>
Maintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards.</li><li>
Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.</li></ul>
Skills:
The Utilization Review Specialist applies clinical expertise and analytical skills daily to evaluate patient care plans against established medical criteria and payer policies. Effective communication skills are essential for collaborating with multidisciplinary teams, including physicians, nurses, and insurance representatives, to gather necessary information and explain review decisions. Organizational skills enable the specialist to manage multiple cases simultaneously while maintaining detailed documentation and meeting deadlines. Proficiency with healthcare IT systems supports efficient data retrieval and documentation of utilization review activities. Continuous learning and adaptability are important to stay updated on regulatory changes and evolving clinical standards, ensuring compliance and optimal patient care.</div>

Utilization Review Specialist

Jamison Pediatrics and Express Care

Job Overview We are seeking a dynamic and detail-oriented Clinical Utilization Specialist to join our healthcare team. In this vital role, you will be responsible for optimizing patient care through comprehensive utilization review, medical documentation review, and case management activities. Your expertise will support clinical decision-making, ensure compliance with healthcare standards, and facilitate efficient resource utilization across inpatient, outpatient, and specialized care settings. This position offers an exciting opportunity to impact patient outcomes positively while working within a collaborative, fast-paced environment dedicated to excellence in healthcare delivery.Responsibilities<ul><li>Conduct thorough utilization reviews for inpatient and outpatient cases, ensuring appropriate level of care based on clinical documentation and established criteria such as NCQA standards and CMS guidelines.</li><li>Review medical records, clinical documentation, and coding (ICD-9, ICD-10, CPT) to verify accuracy, completeness, and compliance with HIPAA regulations.</li><li>Collaborate with physicians, nurses, case managers, and other healthcare professionals to facilitate discharge planning and coordinate patient care transitions across settings such as hospitals, nursing homes, hospice care, or home health agencies.</li><li>Utilize EMR (Electronic Medical Record) systems like Cerner, Epic, Athenahealth, or eClinicalWorks to document findings and support medical management decisions.</li><li>Perform medical coding tasks including ICD coding and DRG assignment to support billing processes and ensure proper reimbursement.</li><li>Participate in clinical documentation improvement initiatives to enhance the accuracy of medical records and optimize reimbursement while maintaining compliance with accreditation standards like NCQA.</li><li>Support utilization management activities by analyzing patient data related to ICU experience, trauma center criteria (Level I &amp; II), pediatrics (PICU), emergency medicine, or primary care cases to promote appropriate resource use.</li></ul>Requirements<ul><li>Proven experience in managed care environments with a strong understanding of Medicare, Medicaid, or commercial insurance protocols.</li><li>LMSW (preferred) Master- Level Non licensed will be considered based off prior experience. </li><li>Critical care experience in settings such as ICU or trauma centers is highly desirable.</li><li>Knowledge of medical terminology, anatomy, physiology, and clinical documentation practices is essential.</li><li>Familiarity with EMR/EHR systems including Cerner, Epic, Athenahealth or similar platforms is required.</li><li>Experience with medical coding (ICD-9/10, CPT), DRG assignment, and utilization review processes is necessary.</li><li>Strong background in hospital or outpatient clinic settings; nursing home or hospice care experience is a plus.</li><li>Ability to interpret complex medical records and ensure compliance with HIPAA regulations.</li><li>Excellent communication skills for collaborating with multidisciplinary teams and explaining clinical findings clearly.</li><li>Certifications such as CCM (Case Management Certification), RHIT/RHIA (Registered Health Information Technician/Administrator), or equivalent are preferred. Join our team to make a meaningful difference in patient care through expert utilization management! We value proactive professionals who thrive in collaborative environments dedicated to healthcare excellence and continuous improvement.</li></ul>Pay: $20.00 - $28.00 per hourWork Location: Hybrid remote in Columbia, SC 29223

Clinical Utilization Specialist

Cottage Health

<div>The Access Case Manager is responsible for utilization review, utilization management, and quality assurance activities for assigned ares of responsibility within the Cottage Health System. Additionally, the case manager will champion, engage, manage and monitor proactive communications and interventions by and between relevant stakeholders with regard to care management. Case management will work collaboratively and proactively with the medical staff, nursing staff and other disciplines to support and achieve the goals of the collaborative care process. Case managers will maintain a working knowledge of regulations and provider contracts governing coverage of inpatient services (i.e., Medicare, Medi-Cal, California Children Services, Genetically Handicapped People Program, Contracted Medical Groups). They will maintain and model interpersonal skills and productive relationships that allow for and support effective interaction with a wide variety of stakeholders. Case managers will consistently demonstrate professionalism and compassion with regard to human dignity, preserving and protecting client autonomy and rights and with respect for patient/family values and beliefs. Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction, and contribution to an overall value-oriented experience of stakeholders and persons served.</div>

Access Case Manager

Providence

<div>Description
Utilization Review RN at Providence System Offices Discovery Park-Irvine, CA. This position is Part-Time and will work 8-hour, Day shifts.
Provide prospective, retrospective, and concurrent utilization reviews for our Southern CA ministries. Conduct clinical reviews and review medical records daily during admission for all payers, as required by the health plans. This role requires a strong clinical background combined with well-developed knowledge and skills in Utilization Management, medical necessity, and patient status determination. The Utilization Management RN must effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment, demonstrating excellent negotiation, communication, problem-solving, and decision-making skills.
Providence caregivers are not simply valued &ndash; they&rsquo;re invaluable. Join our team at Providence California Regional Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.
Required Qualifications:
<ul><li>Associate's Degree in Nursing.</li>
<li>Upon hire: California Registered Nurse License</li>
<li>2 years experience working in a remote UR environment or working as an acute hospital case manager.</li>
</ul>Preferred Qualifications:
<ul><li>Bachelor's Degree in Nursing.</li>
<li>Master's Degree in Nursing.</li>
<li>Experience working with Interqual guidelines.</li>
<li>Experience in a multi-hospital and/or integrated healthcare system.</li>
</ul>Why Join Providence?
Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.
About Providence
At Providence, our strength lies in Our Promise of &ldquo;Know me, care for me, ease my way.&rdquo; Working at our family of organizations means that regardless of your role, we&rsquo;ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.
Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits.
Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
About the Team
The Sisters of Providence and Sisters of St. Joseph of Orange have deep roots in California, bringing health care and education to communities from the redwood forests to the beach shores of Orange county - and everywhere in between. In Southern California, Providence provides care throughout Los Angeles County, Orange County, High Desert and beyond.
Our award-winning and comprehensive medical centers are known for outstanding programs in cancer, cardiology, neurosciences, orthopedics, women's services, emergency and trauma care, pediatrics and neonatal intensive care. Our not-for-profit network provides a full spectrum of care with leading-edge diagnostics and treatment, outpatient health centers, physician groups and clinics, numerous outreach programs, and hospice and home care, and even our own Providence High School.
Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.
Requsition ID: 420761
Company: Providence Jobs
Job Category: Health Information Management
Job Function: Revenue Cycle
Job Schedule: Part time
Job Shift: Day
Career Track: Nursing
Department: 7000 UTILIZATION MGMT OCHD
Address: CA Irvine 15480 Laguna Canyon Rd
Work Location: Providence System Offices Discovery Park-Irvine
Workplace Type: On-site
Pay Range: $57.28 - $88.92
The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.</div>

Utilization Review RN - Part-time - REMOTE

Hospital San Juan Capestrano

<div>PURPOSE STATEMENT:

Manage the client's/patient's/resident&rsquo;s cases with a solid background of clinical knowledge and expertise and may be responsible for providing some therapeutic services to clients/patients/residents.

ESSENTIAL FUNCTIONS:
<ul>
<li>Provide case management and care coordination services for clients/patients/residents in the facility.</li>
<li>Responsible for coordinating continuum of care activities for assigned clients and ensuring optimum utilization of resources, service delivery, and compliance with external agencies and referral sources requirements.</li>
<li>Responsible for psychosocial assessment and for conducting individual, family and group sessions.</li>
<li>Conduct various duties related to coordinating treatment and discharge activities, as needed.</li>
<li>Provide quality care through developing, implementing, managing and evaluating client/patient care plans.</li>
<li>Collect, correlate and provide clinical data to the treatment team.</li>
<li>Convey medical criteria and clinical information between the insurance provider and treatment team as warranted.</li>
<li>May also correlate clinical data for business office as required.</li>
<li>Coordinate in a timely manner, issues or activities relevant to the treatment team.</li>
</ul>
OTHER FUNCTIONS:
<ul><li>Perform other functions and tasks as assigned.</li></ul> 


EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
<ul>
<li>Bachelor&rsquo;s degree in Social Work, Counseling or related human service field required. One or more years of experience working in behavioral health setting. Experience with the patient population served by the facility preferred. Previous experience in case management and/or utilization review preferred.</li></ul> 


LICENSES/DESIGNATIONS/CERTIFICATIONS:
Current license required within the state the facility is operating in if required. First Aid, CPR, de-escalation and restraint certification required (training available upon hire and offered by facility).</div>

Case Manager

Guidehealth

<div>
 
 Company Description
 
 
 
 
 WHO IS GUIDEHEALTH?
 
 
 
 Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides&trade; and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.
 
 
 
 Job Description
 
 
 
 
 Job Description
 
 
 
 We are seeking a
 
 Clinical Care Manager
 
 who is passionate about advancing high‑quality, compliant, patient‑centered care through precise and timely Utilization Review. In this role, you will apply clinical expertise and regulatory knowledge to evaluate healthcare services, ensure medically necessary care, support provider decision-making, and promote effective care coordination.
 
 
 This is a detailed, analytical, and highly collaborative role that directly contributes to the integrity of care management operations and the member experience.
 
 
 
 What You&rsquo;ll Be Doing
 
 
 
 
 Utilization Review &amp; Clinical Determinations
 
 
 
 <ul>
 <li>
 Complete timely review of healthcare services using appropriate medical criteria to support determinations.
 </li>
 <li>
 Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
 </li>
 <li>
 Communicate precertification and concurrent review decisions&mdash;verbally and in writing&mdash;to required parties within defined timeframes.
 
 
 </li>
 </ul>
 
 Clinical Consultation &amp; Collaboration
 
 
 
 <ul>
 <li>
 Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality‑of‑care review.
 </li>
 <li>
 Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives.
 
 
 </li>
 </ul>
 
 Care Coordination &amp; Member Support
 
 
 
 <ul>
 <li>
 Identify and refer eligible members to disease management programs to enhance care quality and continuity.
 </li>
 <li>
 Manage and document on‑call phone communications with members and providers on a rotational basis.
 
 
 </li>
 </ul>
 
 Compliance, Quality &amp; Documentation
 
 
 
 <ul>
 <li>
 Maintain confidentiality of all member information and case records.
 </li>
 <li>
 Participate in quality management initiatives and support related documentation, reporting, data collection, and committee activities.
 </li>
 <li>
 Prepare benefit exhaustion letters upon request.
 </li>
 <li>
 Assist with the design and maintenance of clinical and/or client-specific reports, spreadsheets, and analyses.
 </li>
 <li>
 Maintain current knowledge of relevant regulations, multi‑jurisdictional requirements, medical group guidelines, and URAC standards.
 
 
 </li>
 </ul>
 
 Professional Development
 
 
 
 <ul>
 <li>
 Maintain ongoing professional education and growth aligned with Illinois nursing regulations and contemporary clinical practice.
 
 
 </li>
 </ul>
 Qualifications
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Active, unrestricted Registered Nurse (RN) license in Illinois.
 </li>
 <li>
 5+ years of experience across varied healthcare settings.
 </li>
 <li>
 Knowledge of utilization review, managed care processes, and community health.
 </li>
 <li>
 Meets Illinois CE requirement of 20 hours per 2‑year RN license renewal cycle.
 </li>
 <li>
 Strong proficiency in Microsoft 365 (Word, Excel, PowerPoint, etc.).
 </li>
 <li>
 Excellent written, verbal, and organizational skills.
 </li>
 <li>
 Ability to prioritize effectively amid rapidly changing business needs.
 </li>
 <li>
 Demonstrates strong clinical judgment, compassion, and a positive attitude.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Advanced degree or certification in Case Management, Utilization Review, and/or Quality.
 </li>
 <li>
 Interest in Clinical Informatics.
 </li>
 <li>
 Knowledge of Population Health and Health Disparities.
 </li>
 <li>
 Previous experience in health insurance or managed care settings.
 
 
 </li>
 </ul>
 Additional Information
 
 
 All your information will be kept confidential according to EEO guidelines.
 
 
 
 ALIVE with Purpose: How We Thrive at Guidehealth
 
 
 
 At Guidehealth, our values come to life in everything we do.
 
 
 <ul>
 <li>
 We are Driven by Accountability &mdash; grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike.
 </li>
 <li>
 Always Growing, Always Learning &mdash; staying curious and continuously improving inspires us to shape a better future for healthcare.
 </li>
 <li>
 With Collaborative Innovation, we solve problems creatively, making every experience better for our employees and the patients we serve.
 </li>
 <li>
 At Guidehealth, Every Voice Matters &mdash; we believe our collective strength is rooted in the unique perspectives of each team member.
 </li>
 <li>
 And through Empathy in Action, we build stronger connections with those who count on us.
 </li>
 <li>
 This is what it means to be ALIVE with purpose. This is how we thrive &mdash; together &mdash; at Guidehealth.
 
 
 </li>
 </ul>
 
 BENEFITS:
 
 
 
 While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:
 
 
 <ul>
 <li>
 Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
 </li>
 <li>
 Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
 </li>
 <li>
 Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
 </li>
 <li>
 Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
 </li>
 <li>
 Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
 </li>
 <li>
 Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
 </li>
 <li>
 Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
 </li>
 <li>
 Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.
 
 
 </li>
 </ul>
 All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. Temporary employees and contractors are not eligible for benefits.
 
 
 
 COMPENSATION:
 
 
 
 The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.
 
 
 
 OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT
 
 
 
 Diversity, inclusion, and belonging are at the core of Guidehealth&rsquo;s values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national origin, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other related medical conditions, or any other classification protected by federal, state, and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring, placement, promotion, transfer, demotion, layoff, termination, recruitment advertising, pay, and other forms of compensation, training, and general treatment during employment.
 
 
 
 Our Comittment To Protection Of Patient And Company Data
 
 
 
 This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealth&rsquo;s custodianship as well as Guidehealth Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.
 
 
 As a remote-first organization handling sensitive healthcare data, Guidehealth verifies candidate identity at multiple stages of the hiring and onboarding to safeguard patient privacy, data security, and compliance requirements.
 
 
 
 Remote Work Technical Requirements
 
 
 
 Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection, capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 100 mbps download, 10 mbps upload. Please run a speed test here to confirm your internet connection meets these requirements.
</div>

Utilization Management Registered Nurse

MagnaCare

<div>
 
 Primary Responsibilities
 
 
 
 <ul>
 <li>
 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.
 </li>
 <li>
 Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
 </li>
 <li>
 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.
 </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 and identify potential quality of care issues, service or treatment delays and intervenes or 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. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements.
 </li>
 <li>
 Experience with Complex Medical case reviews including but not limited to: Oncology, Clinical Trials, High Cost Medical Pharmacy and Transplants.
 </li>
 <li>
 Act as a resource for complex case discussions for all staff.
 
 
 </li>
 </ul>
 
 Essential Qualifications
 
 
 
 <ul>
 <li>
 Current licensed Registered Nurse (RN) with state licensure. Must retain active licensure throughout employment.
 </li>
 <li>
 Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
 </li>
 <li>
 Must be able to work independently.
 </li>
 <li>
 Adaptive to a high pace and changing environment.
 </li>
 <li>
 Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
 </li>
 <li>
 Working knowledge of URAC and NCQA.
 </li>
 <li>
 3+ years&rsquo; experience in a UM team within managed care setting.
 </li>
 <li>
 5+ years 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.
 
 
 
 DEI Purpose Statement
 
 
 
 At BHPS, we encourage all team members to bring your authentic selves to work with all of 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.
 
 
 <ul>
 <li>
 We are an Equal Opportunity Employer
 </li>
 </ul>
</div>

Utilization Review Nurse, Complex Care

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