Location: New York,NY, USA
About The RoleAt Brighton Health Plan Solutions (BHPS), we re creating something new and different in health care, and we d love for you to be part of it. Based in New York City, BHPS is a rapidly growing, entrepreneurial health care enablement company bringing tangible innovation to the health care delivery system. Our team is committed to transforming how health care is accessed and delivered. We believe that cost, quality, and population health are optimized when people have long term relationships with their health care providers and that s why we re creating new products that today do not exist anywhere in the New York/New Jersey market. With a growing labor business under the well-known MagnaCare brand, the launch of Create - a new marketplace of health systems focused on self-insured commercial health plan sponsors, and a successful Casualty business, we re fiercely committed to positively impacting our partners.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 ResponsibilitiesSupport Medicare Eligible (MA) members in understanding enrollment options and provide education and guidance through the process.Supports RN with Clinical Outreach and Population Health Initiatives to improve engagement and overall well-being of members.Performs initial patient intake using appropriate screening criteria knowledge and clinical judgment to assess patient s needs.Application and/or interpretation of applicable criteria and clinical guidelines, care management plans, policies, procedures and/or regulatory standards to ensure appropriate care planning.Engages medical providers in development of care plan to address objectives and goals as identified during assessment.Works with patient and providers to achieve better appointment and care compliance to prevent the incurrence of high cost or poor clinical outcomes; works to target the reduction of case complications through identification of high-risk triggers.Supports patient s access to appropriate quality and cost-effective care.Monitors care plans for compliance with periodic follow up with provider and patient.Coordinates with external resources such as Pharmacy Benefit Manager (PBM), and Employee Assistance Plan (EAP) to meet identified needs of the patient and collaborates with providers.Help identify and interpret any trends including systemic issues, access or placement needs and recidivism, and facilitate access to behavioral health services, including assistance with locating providers and scheduling appointments as necessary.Documents all interactions and coordination efforts with both internal and external customers within the same day as the interaction.Presents cases at case strategy meetings. Participate in problem-solving of abrupt changes in care plan or non-compliant providers, and/or patients.Collaborate with internal Utilization Review team and engage colleagues, supervisors, Medical Directors as required by program protocols.Performs other duties as assigned.Essential QualificationsBachelor s degree in social work, or equivalent experience.Current active unrestricted license as an LCSW (as applicable by state law and scope of practice)2+ years of related case management, social work or behavioral health experience with solid clinical knowledge and experience with the treatment planning process, preferred, but not required.Knowledge of Medicare Enrollment Process and requirements.Basic knowledge of personal computer and software for word and excel processing and/or good keyboard skills preferred, or the ability to enter and retrieve data from relevant computer systems.Ability to effectively communicate with all levels of patients, physicians, health care personnel, supervisory staff, and peers.Demonstrates the ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.Demonstrates the willingness to research, learn, and obtain knowledge for the performance of the position.Demonstrates a courteous, professional demeanor and team spirit and the ability to work in a collaborative, effective manner.Preferred QualificationsExcellent self-starter/self-management comfortable with ambiguity.Strong organizational and communication skillsDemonstrate superb decision-making skills by engaging experts while determining alternatives and quickly synthesizing information, deriving insights, and devising solutions.Excellent team player with the ability to consistently demonstrate the highest levels of professionalism, integrity, mutual respect, and accountability to others; ability to maintain strong relationships across key stakeholders and constituents.Start-up mentality and comfortable innovating at a fast paceMust be self-motivated, proactive, and able to work well under pressure.Up to date on regulatory managed care requirementsBilingual Spanish speaking skills preferred but not required.AboutAt 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 MissionTransform the health plan experience how health care is accessed and delivered by bringing outstanding products and services to our partners.Company VisionRedefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.DEI Purpose StatementAt 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 EmployerAnnual Salary Range: $70,000 - $85,000The 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.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: ...@brightonhps.comPowered by JazzHR