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.