About The Role

Brighton Health Plan Solutions (BHPS) provides Case Management/Utilization Review services to its clients. Cases are maintained by the Nurse Case manager. The Nurse Case Manager reports to the Manager of Case Management for clinical activities.

Primary Responsibilities

Is knowledgeable and compliant with all regulatory and statutory regulations that pertain to Case management and self-insured clients, especially ERISA and HIPAA confidentiality requirements.

Assessment of patient needs are accomplished using clinical tools and other data sources.

Individualized care plans are created to encompass all patient needs.

Communicates directly with patients, physicians, DME providers, etc, to secure positive outcomes for patients.

Educate patients and their family members of treatments plans, medications, and goals for successful outcomes.

Establish insurance eligibility coverage for various treatment plans, medications, DME products and other medical costs the patient may incur.

Utilizes internal and external resource and systems to effectively identify and meet member and family needs in response to Case Management requirements.

Determines the appropriate level of care, utilization of resources, and continued needs of patients with complex medical needs, across the continuum of care through application of criteria.

Facilitates and expedites discharge planning.

Maintains accurate records of individual cases.

Evaluates needs for alternative treatment as required.

Ensures each case provides optimal medical care that is cost effective.

Is kind, caring, sympathetic and positive with all customers and fellow employees.

Adheres to established quality assurance standards and all BHPS policies and procedures.

Participates in QA activities.

Essential Qualifications

Current licensed Registered Nurse (RN) with licensure in their state of employment, bachelor's degree preferred.

Case Management Certification, a plus.

Additional certifications such as Diabetes educator, Pediatric Nursing, Gerontological Nursing a bonus.

Must maintain current licensure(s) and specialty certifications that are relevant to this position.

Bachelor's degree preferred.

Minimum of 4 years' experience in a clinical environment preferred.

2 years' experience in Case Management necessary.

Strong skills in medical assessment/medical record review.

Independent problem identification/resolution and critical decision-making skills.

Must be able to prioritize plan and handle multiple tasks/demands simultaneously.

Strong organizational and task prioritization skills.

Excellent customer service skills, including written and oral communication skills.

Ability to define and solve problems, collect data, establish facts and make effective decisions a must.

Ability to work proficiently on a computer (PC) with working knowledge of Microsoft Word, Office and Excel.

Ability to work in a database environment.

Experience with Milliman Care Guidelines (MCG) preferred.

Experience with URAC/NCQA standards.

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, 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 all of your unique abilities.

Brighton Health Plan Solutions 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 healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today's challenges into tomorrow's solutions.

Come be a part of the Brightest Ideas in Healthcare.

Company Mission

Transform the health plan experience - how health care is accessed and delivered - by bringing outstanding products and services to our partners.

Company Vision

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 all team members to bring your authentic selves to work with all 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

Brighton Health Plan Solutions, LLC

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Nurse Case Manager