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’s benefit coverage while working remotely.
Primary Responsibilities
- 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.
Essential Qualifications
- Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Must be able to work independently.
- Must be detail oriented and have strong organizational and time management skills.
- Adaptive to a high pace and changing environment- flexibility in assignment.
- Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
- Proficient in MCG and CMS criteria sets
- Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
- Working knowledge of URAC and NCQA.
- 2+ years’ experience in a UM team within managed care setting.
- 3+ years’ experience in clinical nurse setting preferred.
- TPA Experience preferred.
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