Brighton Health Plan Solutions, LLC

Perform clinical utilization reviews and medical necessity determinations using evidence-based guidelines and national standards. Collaborate with healthcare partners and prepare cases for Medical Director oversight to ensure timely care delivery.

Responsible for creating, auditing, and updating member enrollment profiles while ensuring participants are placed in correct health plans. The role involves troubleshooting eligibility inquiries and collaborating with finance and employer partners to resolve premium issues.

The specialist ensures accurate and compliant medical bill review within the New York workers' compensation and casualty environment. They serve as a subject matter expert to configure bill review rules, workflows, and pricing while training interdepartmental staff.

Lead the strategic direction and operational oversight of contribution accounting and enrollment eligibility for multi-employer health and welfare funds. Ensure accurate processing of employer hours files and contributions while driving process automation and maintaining strong client relationships.

The role involves developing KPIs, statistical models, and predictive analytics to monitor clinical program performance and member outcomes. The analyst will create client-facing dashboards and provide actionable insights to inform healthcare strategy and ROI.