Behavioral Health, Case Management Nurse

Brighton Health Plan Solutions (BHPS) provides Case Management services to its clients. Cases are maintained by Case Managers. The employee reports directly to the Supervisor, Case Management (LCSW). In addition, the role maintains a dotted-line relationship to the Senior Director, Case Management (RN) for clinical guidance, nursing practice standards, and case management program oversight. This position is also responsible for assuring appropriate systems are in place to collect and report program activities and outcomes for case management programs.

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.

• Conduct comprehensive assessments to identify medical, behavioral health, psychosocial, functional, and care coordination needs.
• Develop, implement, monitor, and update individualized, member-centered care plans in collaboration with members, caregivers, providers, and interdisciplinary teams.
• Coordinate care across the healthcare continuum to promote quality outcomes, appropriate utilization, member engagement, and cost-effective care.
• Provide education and coaching to members and caregivers regarding health conditions, treatment plans, medications, preventive care, and self-management strategies.
• Identify and address barriers to care, treatment adherence, health equity, and achievement of care plan goals.
• Facilitate transitions of care and support timely access to medical, behavioral health, and community-based services.
• Perform ongoing outreach, monitoring, reassessment, and follow-up to evaluate progress toward goals and modify care plans as needed.
• Collaborate with members, caregivers, providers, and community resources to support coordination of care and continuity of services.
• Utilize evidence-based guidelines, clinical criteria, nursing judgment, and care management best practices to support clinical decision-making and interventions.
• Identify gaps in care, emerging risks, and opportunities for intervention to improve member outcomes and reduce avoidable utilization.
• Present complex cases during interdisciplinary case reviews and participate in collaborative care planning and problem-solving activities.
• Collaborate with Utilization Management, Population Health, Behavioral Health, Medical Directors, and other internal and external stakeholders to support integrated care delivery.
• Maintain accurate, timely, and complete documentation of assessments, care plans, interventions, member progress, and coordination activities in accordance with organizational, regulatory, and accreditation standards.
• Ensure compliance with NCQA Care Management standards, HIPAA requirements, applicable state and federal regulations, and organizational policies and procedures.
• Participate in quality improvement initiatives, audits, accreditation activities, performance improvement projects, and ongoing professional development.
• Perform other duties as assigned.

• Current, active, unrestricted Registered Nurse (RN) license required.
• Compact (Multistate) Nursing Licensure is required. New York State RN licensure is highly preferred. Candidates who do not currently hold a New York State RN license must be willing and able to obtain NYS licensure within thirty (30) days of hire. The incumbent must maintain all licenses and credentials required to perform the responsibilities of the position.
• Bachelor of Science in Nursing (BSN) preferred;
  Associate Degree in Nursing (ADN) with relevant experience considered.
• Minimum two (2) years of nursing experience in case management, care management, population health, behavioral health, managed care, utilization management, or a related clinical setting; behavioral health experience preferred.
• Experience in behavioral health case management, psychiatric nursing, substance use disorder treatment, integrated care, or coordination of behavioral health services preferred.
• Demonstrated clinical knowledge in assessment, care planning, chronic condition management, behavioral health integration, and care coordination.
• Experience conducting comprehensive clinical assessments and developing individualized, member-centered care plans.
• Knowledge of care management principles, healthcare delivery systems, community resources, and behavioral health service systems.
• Understanding of NCQA Care Management standards, care…