Utilization Management Nurse

Brighton Health Plan Solutions

Utilization Management Nurse providing evaluations of medical necessity for healthcare services. Collaborates with healthcare partners and handles clinical documentation remotely.

Posted 7/30/2026full-timeRemote • Arizona, Connecticut, Florida, Maryland, Minnesota, Missouri, Montana, New Jersey, New York, North Carolina, Ohio, South Carolina, Tennessee, Texas • 🇺🇸 United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in Clinical Utilization Review processes, including proficiency in MCG and CMS criteria sets, while ensuring compliance with regulatory and accreditation standards. Strong organizational skills and the ability to work independently in a fast-paced environment are essential.

Highest-signal resume keywords

Licensed Practical Nurse (LPN)Utilization Review ProcessMCG and CMS Criteria Sets2+ Years Experience in UM TeamWorking Knowledge of URAC and NCQA

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Utilization ReviewBenefit InterpretationMedical and Policy ReviewInpatient and Outpatient ReviewsBehavioral Health ReviewDME ReviewGenetic Testing ReviewClinical Trials ReviewOncology ReviewElective Surgical Cases Review

Soft Skills

Detail OrientedStrong Organizational SkillsTime Management SkillsFlexibilityAbility to Work Independently

Tools & Technologies

Microsoft OfficeOutlookWordExcelPowerPoint

Certifications & Qualifications

Current Licensed Practical Nurse (LPN)

Industry Keywords

Third-Party LiabilityCoordination of BenefitsQuality of Care IssuesMedical Director OversightManaged Care SettingTPA Experience

About the role

Key responsibilities & impact

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.

Requirements

What you’ll need

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.

Benefits

Comp & perks

Health insurance
401(k) matching
Flexible work hours
Paid time off