Nurse Case Manager, Case Management

About The Role

Brighton Health Plan Solutions (BHPS) provides Case Management services to its clients. Cases are maintained by the Nurse Case manager. The Nurse Case Manager reports to the Manager of Case Management. Responsible for developing and managing the case management program and providing case management services to members. This position is also responsible for assuring appropriate systems are in place to collect and report program activities and outcomes for case management program.

Primary Responsibilities

• Adheres to regulatory regulations (e.g., ERISA, HIPAA) for Case Management and self-insured clients.
• Uses clinical tools for patient assessment, creating individualized care plans.
• Communicates with patients, physicians, DME providers, etc., to ensure positive outcomes.
• Educates patients and family about treatment plans, medications, and goals.
• Establishes insurance coverage eligibility for medical costs.
• Utilizes internal and external resources for Case Management.
• Determines appropriate care level and resource utilization for complex cases.
• Facilitates discharge planning and evaluates alternative treatments.
• Maintains accurate records of cases, ensuring cost-effective care.
• Demonstrates compassion, care, and positivity with customers and colleagues.
• Adheres to BHPS policies and quality assurance standards.
• Participates in QA activities.

Essential Qualifications

• Maintain relevant licensure(s), specialty certifications, and Case Management Certification.
• 2 years’ Case Management experience required, preferably with 4 years' clinical experience.
• Strong medical assessment/record review skills for effective problem-solving and decision-making.
• Independent problem resolution and critical decision-making abilities.
• Excellent prioritization, planning, and multitasking skills.
• Effective customer service, communication, and organizational skills.
• Proficiency in Microsoft Word, Office, Excel, and working in a database environment.
• Familiarity with URAC/NCQA standards, Milliman Care Guidelines (MCG) experience preferred.
• Bonus: Additional certifications like Diabetes educator, Pediatric Nursing, Gerontological Nursing, Maternity Nursing, Population health, Disease Management.
• Current licensed Registered Nurse (RN) with compact state licensure; bachelor’s degree preferred.

* General Knowledge of HIPAA Confidentiality Laws

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 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 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