About The Role  Brighton Health Plan Solutions (BHPS) provides Utilization Review/Medical and Case Management services for Group Health and Workers’ Compensation and other Casualty clients.  The Workers’ Compensation Nurse Case Reviewer collaborates with medical care providers, employers, employees, and at times, attorneys to support the appropriate return to work, the provision of necessary medical services, and the evaluation of coverage under the Plan.  The Nurse Case Reviewer reports to the Casualty Department Manager.   Primary Responsibilities  + Collaborates with workers' compensation patients, employers, providers, and claims adjusters to coordinate medical and disability services for timely return to work.  + Provides utilization review, continued stay reviews, and utilization management based on clinical judgment and state WCB Medical Treatment Guidelines.  + Knowledgeable and compliant with New York State Workers’ Compensation Law, Medical Treatment Guidelines, ERISA, HIPAA confidentiality requirements, and NY Formulary Review process.  + Proven ability to anticipate claimant's treatment or recovery milestones.  + Provides Case Management services, including assessing barriers to recovery and determining treatment alternatives.  + Facilitates and expedites discharge planning as needed.  + Produces accurate electronic records of individual cases.  + Ensures timely, cost-effective medical care for injured workers' recovery.  + Answers provider calls and assists with Casualty Department workload as necessary.  + Kind, caring, and positive with all customers and fellow employees.  + Adheres to established quality assurance standards and MagnaCare policies and procedures.  + Participates in up to 10% of employed time in QA activities.  Essential Qualifications  + Currently licensed Registered Nurse (RN)  + Must maintain current licensure(s) and specialty certifications that are relevant to this position; CCM is encouraged.  + Bachelor’s degree preferred.  + Minimum of 4 years’ experience in a clinical environment required.  + Previous workers’ compensation case management experience required.  + Previous experience in utilization review/medical management preferred.  + Strong skills in medical assessment/medical record review.  + Excellent customer service skills.  + Ability to define and solve problems, collect data, establish facts and make effective decisions a must.   + Must be detail oriented and have strong organizational and time management skills, and the ability to work independently   + Ability to work proficiently on a computer (PC) with working knowledge of Microsoft Office, especially Word, Excel and Outlook.  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   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 Powered by JazzHR