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About The Role

Brighton Health Plan Solutions, a full-service health plan administrator is looking for a full-time dynamic clinical leader who will provide leadership, oversight and accountability for our Clinical Services and Casualty departments. In partnership with the CMO, the VP of Clinical Operations role will serve as a key stakeholder, decision maker and catalyst for achieving corporate goals through delivery of quality driven, clinically effective and cost-effective services. This role will be responsible in design and implementation of the department’s processes and services that meets the needs of our commercial and worker’s compensation self-funded clients. The VP needs to have a passion to make healthcare more effective and affordable and will be responsible for the Casualty and Clinical Services departments which in turn includes Utilization Management, Case Management and Population Health divisions.  The position can be remote, or on-site our New York or New Jersey.

Primary Responsibilities

+ Through governance and performance monitoring, oversees all Clinical Services (CS) functions (prior authorization, concurrent review, appeals, case management, disease management, population health) per defined Client agreements.

+ Through governance and performance monitoring, oversees all Workers’ Compensation (WC) Case Management and Utilization Review (UR) Programs.

+ Collaborates with the Chief Medical Officer on evaluation of departmental policies and procedures to ensure continuous process and quality improvement within the Department.

+ Develops and drives metrics leading to process improvement and staff accountability.

+ Is knowledgeable of, adheres to and enforces compliance with all regulatory and statutory regulations that pertain to CS, especially ERISA and HIPAA confidentiality requirements.

+ Is knowledgeable of, adheres to and enforces compliance with all regulatory and statutory regulations that pertain to WC, especially NYS Workers’ Compensation, NYS WC Alternate Dispute Resolution (ADR) Programs, and WC Certified PPO Programs.

+ Coordinates and participates in all WC State Reporting and CS URAC / regulatory audits.

+ Assists CMO in creating and managing work plans, program descriptions, policies and procedures required for URAC accreditation, NCQA readiness / accreditation and other regulatory requirements and to maintain departmental audit readiness.

+ Assists CMO in driving high-cost initiatives and payment integrity initiatives for CS and WC departments through strong partnership with Finance, Network, Customer Service, Operations and other departments.

+ Participates in internal/external departmental and inter-departmental meetings relevant to core requirements.

+ Implements new integrated programs as needed to meet Client requests and work with CMO to set goals, engage internal departments and external vendors as needed.

+ Assists CMO with preparation of Client presentations and RFI / RFP presentation materials.

+ Participates in implementation projects including leading work streams and serving as a liaison between internal and external stakeholders for new Clients.

+ Discusses and documents any concerns, complaints and/or issues with Chief Medical Officer.

+ Effectively communicates with direct reports through scheduled quarterly performance conversations and Ad Hoc 1:1 meetings as well as huddles.

+ Evaluates needs for alternative training and assessment of staff. Arrange for staff and training, establishing requirements for goals and developing reporting that meet auditing standards.

+ Encourages and supports each staff member in their drive towards performance excellence and assesses staff quarterly and provides constructive and impactful feedback.

+ Serves as a subject matter expert and role model for staff, demonstrating quality customer service and consistently maintaining a positive work environment.

+ Maintains professional and productive relationships will all clients and vendors.

+ Coordinates and participates in all WC State Reporting and audits.

Essential Qualifications

+ Currently licensed Registered Nurse (RN), Nurse Practitioner (NP), or Physician Assistant (PA) with appropriate licensure.

+ Must maintain current licensure(s) and specialty certifications that are relevant to this position.

+ Minimum of 4 years’ experience in a clinical environment required.

+ Strong skills in management of a clinical team.

+ Previous Utilization Management experience required.

+ Previous experience in Case Management preferred.

+ Previous experience in Workers’ Compensation preferred.

+ Ability to articulate business case to support management initiatives and influence outcomes.

+ Approachable, positive demeanor with hands on and team focused work style.

+ Demonstrates ability to collaborate across a company including conflict resolution, solution oriented and team building abilities.

+ In depth knowledge of diverse business functions and principles.

+ Working knowledge of data analysis and performance/operation metrics.

+ Ability to define and solve problems, collect data, establish facts and make effective decisions a must.

+ Ability to work proficiently on a computer (PC) with knowledge of Microsoft Word and Excel.

+ Ability to work in a database environment a plus.

*General knowledge of HIPAA Confidentiality Laws

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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