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Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.
SCOPE OF ROLE
The Utilization Management Nurse uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. This role makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed while following established guidelines/procedures.
The Utilization Management Nurse job description is intended to point out major responsibilities within the role, but it is not limited to these items.
- Provides first level clinical review for all medical and surgical authorization requests against applicable criteria, policies and procedures. Accurately documents all reviews and contacts providers and members according to established timeframes.
- Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost-effective care delivery.
- Screening and coordination of cases within the utilization management department and other Bright clinical teams including Case Management, Care Navigation and Transitions of Care to ensure optimal care for members
- Escalates all potential quality issues and grievances to correct Bright workflows
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Minimum of 2 years clinical experience in hospital acute care experience with a broad background to include ICU, CCU, ER and Med Surg and/or a combination of skilled, rehabilitation, or long-term care.
- Three (3)+ years of utilization management/quality improvement experience.
- Working knowledge and understanding of basic utilization management concepts.
- Experience interpreting clinical criteria into clear determinations.
- Must possess strong organizational and prioritization skills and competence and capacity to handle multiple initiatives while managing conflicting priorities.
- Excellent writing skills, particularly in determination notification writing.
- Must be self-motivated, able to take initiative, and ability to thrive and drive results in a collaborative environment.
- Experience in using the Microsoft Office Suite including Excel and Word as well as demonstrated ability to learn/adapt to other computer-based systems and tools.
LICENSURES AND CERTIFICATIONS
- An active, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license to practice as a health professional in a state or territory of the United States is required for this role.
- The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
- Some travel may be required.
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.