Utilization Management Pre-Service Nurse

SCOPE OF ROLE 

The Pre-Service Review Nurse uses clinical knowledge, communication skills, and independent critical thinking skills to interpret criteria, policies, and procedures to provide the best and most appropriate treatment, care, or services for members.

ROLE RESPONSIBILITIES

The Pre-Service Review Nurse job description is intended to point out major responsibilities within the role, but it is not limited to these items.

• Provides a 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 healthcare 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, and Discharge Planning to ensure optimal care for members.
• Escalates all potential quality issues and grievances to correct Bright workflows

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s or Associate’s degree in Nursing required.
• Three (3) or more years of utilization management and quality improvement experience required.
• Working knowledge and understanding of basic utilization management concepts required.

PROFESSIONAL COMPETENCIES

• 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 able 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.

WORK ENVIRONMENT

• 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.
• Travel may be required.

For individuals assigned to a location(s) in California, Bright Health is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $27.54 - $41.31 hourly.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; up to 21 days of PTO, 10 paid holidays, plus 2 floating holidays per year; and a lifestyle spending account.