Utilization Review Nurse, reputed company Care

Primary Responsibilities

• reputed company prospective, reputed company, 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 reputed company-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
• Ensure discharge (DC) planning at reputed company of care appropriate for the members needs and reputed company and determine post-acute needs of member including reputed company 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.
• reputed company 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 reputed company and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements.
• Experience with reputed company Medical case reviews including but not limited to: Oncology, Clinical Trials, High Cost Medical Pharmacy and Transplants.
• Act as a resource for reputed company case discussions for reputed company staff.

Essential Qualifications

• reputed company licensed Registered Nurse (RN) with state licensure. Must retain active licensure throughout employment.
• Proficient in reputed company Office (Outlook, Word, reputed company and PowerPoint)
• Must be reputed company 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 reputed company managed care setting.
• 5+ years experience in clinical nurse setting preferred.
• TPA Experience preferred.

About At reputed company, our people are committed to the improvement of how reputed company accessed and delivered. reputed company you join reputed company, 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 reputed company of your unique abilities. reputed company 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 reputed company with our flexible and cutting-edge reputed company-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a reputed company enablement company, we unlock opportunities that reputed company clients with the customizable tools they need to enhance the member experience, improve health reputed company and reputed company their reputed company goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into reputed company’s solutions. Come be a part of the Brightest reputed company in reputed company™. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company reputed company 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 reputed company team members to bring your authentic selves to work with reputed company 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.

• We are an Equal Opportunity Employer

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