About The Role
Brighton Health Plan Solutions (BHPS) provides Case Management services to its clients. Cases are maintained by Case Managers. The employee reports directly to the Supervisor, Case Management (LCSW). In addition, the role maintains a dotted-line relationship to the Senior Director, Case Management (RN) for clinical guidance, nursing practice standards, and case management program oversight. This position is also responsible for assuring appropriate systems are in place to collect and report program activities and outcomes for case management programs. 
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities, and activities may change, or new ones may be assigned at any time with or without notice.

Primary Responsibilities

Conduct comprehensive assessments to identify medical, behavioral health, psychosocial, functional, and care coordination needs.

Develop, implement, monitor, and update individualized, member-centered care plans in collaboration with members, caregivers, providers, and interdisciplinary teams.

Coordinate care across the healthcare continuum to promote quality outcomes, appropriate utilization, member engagement, and cost-effective care.

Provide education and coaching to members and caregivers regarding health conditions, treatment plans, medications, preventive care, and self-management strategies.

Identify and address barriers to care, treatment adherence, health equity, and achievement of care plan goals.

Facilitate transitions of care and support timely access to medical, behavioral health, and community-based services.

Perform ongoing outreach, monitoring, reassessment, and follow-up to evaluate progress toward goals and modify care plans as needed.

Collaborate with members, caregivers, providers, and community resources to support coordination of care and continuity of services.

Utilize evidence-based guidelines, clinical criteria, nursing judgment, and care management best practices to support clinical decision-making and interventions.

Identify gaps in care, emerging risks, and opportunities for intervention to improve member outcomes and reduce avoidable utilization.

Present complex cases during interdisciplinary case reviews and participate in collaborative care planning and problem-solving activities.

Collaborate with Utilization Management, Population Health, Behavioral Health, Medical Directors, and other internal and external stakeholders to support integrated care delivery.

Maintain accurate, timely, and complete documentation of assessments, care plans, interventions, member progress, and coordination activities in accordance with organizational, regulatory, and accreditation standards.

Ensure compliance with NCQA Care Management standards, HIPAA requirements, applicable state and federal regulations, and organizational policies and procedures.

Participate in quality improvement initiatives, audits, accreditation activities, performance improvement projects, and ongoing professional development.

Perform other duties as assigned.

Essential Qualifications

Current, active, unrestricted Registered Nurse (RN) license required.

Compact (Multistate) Nursing Licensure is required. New York State RN licensure is highly preferred. Candidates who do not currently hold a New York State RN license must be willing and able to obtain NYS licensure within thirty (30) days of hire. The incumbent must maintain all licenses and credentials required to perform the responsibilities of the position.

Bachelor of Science in Nursing (BSN) preferred; Associate Degree in Nursing (ADN) with relevant experience considered.

Minimum two (2) years of nursing experience in case management, care management, population health, behavioral health, managed care, utilization management, or a related clinical setting; behavioral health experience preferred.

Experience in behavioral health case management, psychiatric nursing, substance use disorder treatment, integrated care, or coordination of behavioral health services preferred.

Demonstrated clinical knowledge in assessment, care planning, chronic condition management, behavioral health integration, and care coordination.

Experience conducting comprehensive clinical assessments and developing individualized, member-centered care plans.

Knowledge of care management principles, healthcare delivery systems, community resources, and behavioral health service systems.

Understanding of NCQA Care Management standards, care coordination best practices, and applicable state and federal regulatory requirements.

Strong clinical assessment, medical record review, critical thinking, and problem-solving skills.

Ability to identify care gaps, barriers to care, and opportunities to improve member outcomes.

Excellent verbal and written communication skills, with the ability to effectively engage members, caregivers, providers, and interdisciplinary teams.

Demonstrated ability to prioritize workload, manage multiple assignments, and work independently with minimal supervision.

Proficiency in Microsoft Office applications and experience working within electronic medical record, case management, and database systems.

Commitment to maintaining member confidentiality and compliance with HIPAA and other applicable regulations.

Ability to adapt to changing priorities and support organizational goals, quality initiatives, and accreditation requirements.

Preferred Qualifications

Bachelor of Science in Nursing (BSN).

Certified Case Manager (CCM), Accredited Case Manager (ACM), Behavioral Health certification, or other relevant certification preferred.

Experience in managed care, Medicare, Medicaid, commercial health plans, or population health programs.

Experience working within an NCQA-accredited health plan and applying NCQA Care Management standards, including assessment, care planning, care coordination, transitions of care, and ongoing member monitoring, strongly preferred.

Knowledge of evidence-based care management practices, motivational interviewing, and member engagement strategies.

Strong organizational, analytical, and decision-making skills.

Demonstrated ability to collaborate effectively across multidisciplinary teams and with community-based providers and resources.

Self-motivated, proactive, and comfortable working in a fast-paced environment with competing priorities.

Knowledge of healthcare regulations, quality improvement methodologies, and managed care requirements.

Bilingual Spanish-speaking skills preferred but not required.

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

JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com

Behavioral Health, Case Management Nurse

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