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About The Role

The Director, Utilization Management (UM) will manage the Utilization Management team consisting of Clinicians and Non-Clinical support staff from Intake through Appeals processing. The ideal candidate will have a strong clinical background within a managed care setting including a high-level understanding of prior authorization process from beginning of ingestion at Intake level through reviews: including inpatient/concurrent reviews, outpatient, and retrospective reviews, Physician reviews and Appeals and Grievances processing.

Primary Responsibilities

+ Reporting to the Vice President of Clinical Operations, will also collaborate with other internal organizational leaders to ensure a regulatory compliant program.

+ Support executive team in implementation of client onboardings with time sensitive requirements.

+ Support and grow the utilization management team through strong professional relationships, mentorship, modelling of ownership, and independent critical thinking.

+ Establish cross functional relationships with Clinical Program stakeholders to ensure optimal partnerships and integration with our Case Management and Clinical Program teams.

+ Extensive knowledge of URAC and NCQA accreditation requirements and the functions they play within the Utilization Management Department and throughout the organization.

+ Partner with Clinical Program leaders to execute on programmatic audit results and ensure existing and new regulatory initiatives.

+ Review multiple reports for statistical and financial tracking purposes to identify utilization trends supporting financial forecasting.

+ Comprehensive understanding of regulatory, accreditation, and contractual obligations as they apply to and drive day to day operations and oversight of the UM program.

+ Lead, develop and manage processes to respond, solution, and provide guidance to assist in operational questions and/or escalated UM cases from delegates, Care Partners, Providers, and internal staff.

+ Cross Collaboration with leadership in Case Management/Disease Management to ensure healthcare initiatives are successful, including development and execution of new and existing programs.

+ Overseeing UM Department preparations and responses to regulatory audits and the construction of corrective action plans.

+ Participating in regulatory audits related to all aspects of utilization management.

+ Tracking, analyzing, and developing strategies to address outlier performance of utilization metrics and reporting on metrics at a regular cadence.

+ Providing input into member/Provider/DOI/DOL complaints and escalations related to Clinical Reviews.

+ Support identification of education needs and trainings for providers in collaboration with the Provider Services Department.

+ Participating in advisory groups and clinical committees.

Essential Qualifications

+ Active and unrestricted license as a Registered Nurse (RN).

+ Bachelor’s degree in nursing, (or equivalent experience within managed care environment).

+ 8 or more years of professional experience including 5+years developing/managing Utilization Management operations.

+ Experience with accreditation bodies (URAQ/NCQA).

+ Prior Experience with leadership including Hiring, WFM, Staff Performance.

+ Organized with the ability to define and solve problems, collect data, establish facts, follow-up, and make decisions for current and future needs.

+ Strong team and leadership skills.

+ Must be detail oriented and have strong organizational and time management skills, and the ability to work independently.

+ Proficient in Microsoft Word, Excel and Outlook.

Preferred Qualifications

+ Experience working within a TPA environment.

+ Experience with Case Management

+ Familiarity with call center operations

+ Experience in health platform build and implementation.

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

DEI Purpose Statement

At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities.   We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace.  We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.

*We are an Equal Opportunity Employer

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