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Clinical Case Manager
2 months ago
Brighton Health Plan Solutions (BHPS) is dedicated to delivering exceptional Case Management services to our clients. The Nurse Case Manager plays a pivotal role in overseeing cases and is accountable to the Manager of Case Management. This position is essential for the development and management of the case management program, ensuring that comprehensive services are provided to our members. Additionally, the Nurse Case Manager is tasked with implementing systems to effectively collect and report on program activities and outcomes related to case management.
Key Responsibilities
- Complies with regulatory standards (e.g., ERISA, HIPAA) pertinent to Case Management and self-insured clients
- Employs clinical assessment tools to create tailored care plans for patients
- Engages with patients, healthcare providers, and DME suppliers to secure optimal outcomes
- Informs patients and their families about treatment protocols, medications, and objectives
- Verifies insurance coverage for medical expenses
- Utilizes both internal and external resources for effective Case Management
- Assesses appropriate care levels and resource allocation for complex cases
- Facilitates discharge planning and explores alternative treatment options
- Keeps precise records of cases to ensure cost-effective care delivery
- Exhibits empathy, care, and positivity in interactions with clients and colleagues
- Adheres to BHPS policies and maintains quality assurance standards
- Participates in quality assurance initiatives
- Possesses relevant licensure(s), specialty certifications, and Case Management Certification
- Minimum of 2 years of Case Management experience, with a preference for 4 years of clinical experience
- Demonstrates strong medical assessment and record review capabilities for effective problem-solving
- Exhibits independent problem-solving and critical decision-making skills
- Possesses excellent prioritization, planning, and multitasking abilities
- Displays effective customer service, communication, and organizational skills
- Proficient in Microsoft Word, Office, Excel, and database management
- Familiarity with URAC/NCQA standards; experience with Milliman Care Guidelines (MCG) is a plus
- Bonus: Additional certifications such as Diabetes Educator, Pediatric Nursing, or Gerontological Nursing
- Current Registered Nurse (RN) license with state licensure; a bachelor's degree is preferred
At Brighton Health Plan Solutions, LLC, we are committed to enhancing the accessibility and delivery of healthcare. Our culture is diverse and welcoming, emphasizing encouragement, respect, and the promotion of diversity, inclusion, and belonging at every level. We value authenticity and encourage our team members to bring their unique abilities to the workplace.
Brighton Health Plan Solutions collaborates with self-insured employers, Taft-Hartley Trusts, health systems, providers, and other TPAs, addressing contemporary healthcare challenges through our innovative third-party administration services. Our extensive experience in health plan management, proprietary provider networks, and advanced technology platform enables us to provide clients with customizable tools that enhance member experiences, improve health outcomes, and achieve healthcare objectives. Together with our trusted partners, we are transforming the health plan experience, turning today's challenges into tomorrow's solutions.
Company Mission
To transform the health plan experience by delivering outstanding products and services to our partners.
Company Vision
To redefine healthcare quality and value by aligning the incentives of our partners in innovative ways.
DEI Purpose Statement
At BHPS, we encourage all team members to bring their authentic selves to work, embracing the richness of their unique experiences. We are committed to fostering a culture that prioritizes diversity, inclusion, and a sense of belonging at every level.
- We are an Equal Opportunity Employer
