Job Description

Job Description

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 Manager 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 case management, utilization review, continued stay reviews, and 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

Essential Qualifications

• Currently licensed Registered Nurse in the state of NY, or the ability to obtain
• Maintain current licensure(s) and specialty certifications that are relevant to this position; CCM is encouraged
• Minimum 1 year experience in worker’s compensation case management
• Bachelor’s degree preferred
• Minimum of 4 years’ experience in a clinical environment required
• 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 Teams, and Outlook

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