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Job Details

Medical Director - Medicare Advantage at Bright Health
Minneapolis, MN, US
Bright Health will deliver a smarter, more connected healthcare experience. The company’s affordable health insurance plans, exclusive partnerships with leading health systems, and simple, friendly approach to technology are reshaping how people and physicians achieve better health together. Today, Bright Health provides Individual and Family Plan and Medicare Advantage health insurance in three markets, and will be expanding to other geographies and adding SNP plans in 2019. 
 
We are united by a common vision: To deliver the best healthcare experience by putting brilliant minds, empathetic hearts and personalized technology to work to create meaningful relationships between our members and Care Partners.
 
Our mission? Making Healthcare Right. Together.
 
YOUR RESPONSIBILITIES 
As the Medical Director of our Medicare Plans, you will have influence over the Medicare Advantage and SNP Plans in several markets with different health care system partners.  You will be responsible for promoting and managing our differentiated Joint Model of Healthcare with health systems and clinically integrated networks in multiple markets, as well as adapting processes to market specific conditions.  You will be responsible for providing clinical expertise and business direction to support medical management and pharmacy programs. You will deeply collaborate with the Executive Team at Bright Health and will inform our corporate clinical strategy.  You will have extensive interactions with our Care Partner’s Executive Team and Physician Leadership, in presenting plan performance, and managing toward jointly held outcomes goals. 

 

    • Work to achieve the health optimization performance objectives for each market (quality, savings, risk and experience) within the constraints of the benefit design, bid, and network configuration
    • Operationalize the elements of medical management across our Medicare Advantage and SNP products in all markets in concert with care partners
    • Actively participate in, and work against metrics in these domains:
    • -- Population Health Management: Utilization Management, Early Risk Identification
    • -- Network Management: Adequacy, Contracting, OON requests
    • -- Quality: CCIPS Implementation, STARS Optimization
    • -- Clinical Compliance: Appeals & Grievances, FWA monitoring, Compliance reporting
    • -- Advanced Delivery Models
    • -- Risk Adjustment
    • Support the medical management staff ensuring timely and consistent responses to members and care partners
    • Act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs
    • Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities: P&T Committee, Quality Committees, Credentialing Committees, Utilization Management Committees, and Joint Operating Committees
    • Responsible for supporting predetermination reviews and reviews of claim determinations, providing clinical, coding, and reimbursement expertise
    • Craft and implement interventions that improve outcomes
    • Promote approaches that can improve clinical practice performance while achieving similar or greater clinical quality
    • Actively participate in the Quality Management program and oversight of any clinical Quality Improvement Projects, including developing and co-managing Chronic Care Improvement Projects by market
    • Develop, maintain and assure compliance with physician review policies and procedures (including timeliness) for utilization management and support case management
    • Support collaborative relationships with physicians, large provider groups, hospitals, other facilities and ancillary providers
    • Support Provider Education efforts

ABOUT YOU

      • 5+ years’ experience in Clinical Practice and the Health Care Industry
      • 3+ years’ experience and leadership in Medicare Advantage health plan products
      • Strong understanding of CMS rules and guidelines
      • You have post-graduate experience in direct patient care
      • Previous leadership experience in a clinical oversight role
      • MD or DO Board Certification
      • Unrestricted License
      • MPH/MHA/MBA or 3+ years’ experience in payer environment
In addition to the above experience, we want you to be deeply motivated to join an organization that places relationships at the center of better healthcare delivery. Like others on our team, you are humble, mature, and check your ego at the door. You are brave and always challenge the status quo, but respectful and have an open mind. You are excited to take ownership at an early stage of our company. 
We've won some fun awards like: Great Places to WorkModern HealthcareForbes, 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!
 
BRIGHT ON!