Nurse Case Manager, Case Management

Brighton Health Plan Solutions, LLC•Chapel Hill, NC

12d

About The Position

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.

Requirements

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.
Current licensed Registered Nurse (RN) with compact state licensure; bachelor’s degree preferred.
General Knowledge of HIPAA Confidentiality Laws

Nice To Haves

Additional certifications like Diabetes educator, Pediatric Nursing, Gerontological Nursing, Maternity Nursing, Population health, Disease Management.

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.