The Director, Utilization Management will collaborate with clinical leaders to build and implement solutions that align with Bright’s overall clinical management strategy and deliver excellent compliance and medical cost results in alignment with Bright Health’s Care Partner strategic approach.
The Director, Utilization Management is responsible for building and leading a team responsible for the execution of Utilization Management initiatives including pre-service, concurrent, retrospective reviews. This is a senior role within Bright Health’s Clinical Leadership accountable for establishing and operating the new Utilization Management team. Responsibilities include coordinating with cross functional leaders to understand how utilization management supports the plan’s business strategy, providing direct leadership of utilization management clinical and non-clinical teams, establishing standard operating procedures in alignment with program policies and developing staffing models that scale with Bright’s growth. The Director, Utilization Management ensures applicable programs meet all applicable state/federal regulations and URAC accreditation standards requirements.
- Build and oversee utilization management teams and solutions that yield industry-leading medical cost outcomes while aligning with Bright’s Care Partner philosophy
- Collaborate with Bright’s Medical Directors to establish clinical strategies that enhance program performance and align with Bright’s core objectives, policies and values
- Support development and maintain policies and procedures related to corresponding utilization management functions
- Coordinate with other leaders of internal and delegated functions at Bright, including care management, care navigation, clinical market teams, claims and line of business leaders, to identify opportunities to smooth the member and provider experience across programs
- Contribute to the development of methodology and processes to measure, and evaluate, ongoing clinical program performance
- Establish monitoring processes to validate and document that all of Bright’s UM processes meet URAC Health Plan Utilization Management (HUM) accreditation standards and State and Federal regulatory requirements
- Participate in and/or lead the implementation of new clinical initiatives and/or new market installations in relation to utilization management
- Develop and maintain staffing and scheduling plans to meet departmental objectives as provided by leadership, including meeting specified service levels (e.g. average speed of answer and abandonment rates)
- Represent the Utilization Management function within Bright Committee structures to report program performance and provide operational updates including facilitation and participation on the Bright Health Utilization Management Committee, reporting program performance and operational updates
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor’s degree in a related field required
- An RN or other clinical licensure is preferred, but not required
- Eight (8) or more years of professional experience, including five (5) years developing and/or managing clinical programs, products and services required
- At least two (2) years of experience working within a utilization management operation required
- Prior experience with URAC accreditation strongly preferred
- Formal training in Six Sigma management techniques preferred
- Strong operational mindset and ability to use data to draw insights
- Thrive and drive results in a collaborative environment
- Strong ability to communicate in written and verbal presentations
- Strong team leadership skills
At Bright Health, we brought together the brightest minds from the health care industry and consumer technology and together we created Bright Health: a new, brighter approach to healthcare, built for individuals. Our plans are easy to manage, personalized and more affordable, giving people the quality care they deserve. Through our exclusive care partnerships with leading health systems in local communities we are reshaping how people and physicians achieve better health together.
We’re Making Healthcare Right. Together.
We've won some fun awards like: Great Places to Work, Modern Healthcare, Forbes, etc. But more than anything, we're a group of people who are really dedicated to our mission in healthcare. Come join our growing team!
As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.