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.
As the Medical Director of our Individual and Family Plan, you will have influence over the Individual and Family Plans in several markets with different health care system partners. You will be responsible for developing and overseeing our unique and differentiated care model for our under 65-year-old populations, and will be responsible for providing clinical expertise and business direction to support medical management programs. You will deeply collaborate with the Executive Team at Bright Health and will inform our corporate clinical strategy. In addition, you will have extensive interactions with our Care Partner’s Executive Team and Physician Leadership.
YOU CAN ANTICIPATE YOU WILL:
Work to achieve the health optimization performance objectives for each market (quality, savings, risk and experience) within the constraints of the benefit design, network configuration/rates
Operationalize the elements of medical management across our Individual product 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, Credentialing, OON requests
Quality: QIPS Implementation, HEDIS gap closure, Coding, Accreditation
Clinical Compliance: Appeals & Grievances, FWA monitoring, Compliance reporting
Advanced Delivery Models
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, UM Sub-committee
Responsible for predetermination reviews and reviews of claim determinations, providing clinical, coding, and reimbursement expertise
Craft and implement interventions that improve outcomes
Provide alternative approaches that can improve practice performance while achieving similar or greater clinical quality
Actively participate in the Quality Management program and oversight of any clinical Quality Improvement Projects
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
5+ years’ experience in Clinical Practice and the Health Care Industry
3+ years’ experience and leadership in ACA Individual health plan products
You have post-graduate experience in direct patient care
Previous leadership experience in a clinical oversight role
MD or DO Board Certification
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.