Nurse Case Manager, Maternity

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 maternity case management program and providing case management services to pregnant members and follow-up care to mother and baby. This position is also responsible for assuring appropriate systems are in place to collect and report program activities and outcomes.

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

• Identifies and assess all pregnant members to determine risk and necessary pre/postnatal management interventions.
• Conduct telephonic assessments to evaluate the health and social needs of Maternity care Members/Families.
• Development of Care Plans in collaboration with Members and Providers.
• Collaborate with healthcare providers (including: obstetricians, midwives, and other specialists) to ensure seamless and coordinated care for Mothers and expected Child(ren).
• Facilitate communication between all members of the healthcare team to optimize outcomes.
• Support and manage maternity incentive programs including ancillary vendor communications and tracking as needed.
• Partner with internal UM staff And Medical Directors to ensure seamless transition of member needs for prior authorization through delivery of care.
• Determines appropriate care level and resource utilization for complex cases.
• Maintains accurate records of cases, ensuring cost-effective care.

Essential Qualifications

• 2 years’ Case Management experience required, preferably with minimum of 4 years' clinical experience in maternity/OB settings.
• 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 state licensure; bachelor’s degree preferred.
• CCM Certification preferred.

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

Annual Salary Range: $70,000 - $85,000

The salary range and/or hourly rate listed is a good faith determination that may be offered to a successful applicant for this position at the time of the posting of an advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable by law including but not limited to location, years of relevant experience, education, credentials, skills, budget and internal equity.

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