Brighton Health Plan Solutions, LLC

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.

The Clinical Appeal Nurse is responsible for conducting daily clinical and benefit reviews for pre and post-service medical necessity appeals and quality of care grievances. They must collaborate with internal Medical Directors and external review organizations to ensure accurate, timely, and compliant case resolutions.

The Utilization Management Nurse conducts clinical utilization reviews based on evidence-based guidelines and internal policies, focusing on medical necessity and benefit coverage. Responsibilities also include identifying potential Third-Party Liability cases, collaborating with healthcare partners, and preparing case presentations for Medical Director oversight.