“Making Healthcare Right. Together.” is the cornerstone of all we do. Our vision is through powerful relationships with Care Partners, we help all people live healthy and brighter lives. To successfully achieve our mission and vision as we operate in a dynamic health care environment, we expect Bright employees to embody and uphold our core values in work and interactions, both internal and external: be brave, be brilliant, be accountable, be inclusive, and be collaborative.
MISSION, VISION AND VALUES
“Making Healthcare Right. Together.” is the cornerstone of all we do. Our vision is to collaborate with Care Partners to make health care simpler, personal and more affordable. To successfully achieve our mission and vision as we operate in a dynamic health care environment, we expect Bright People to embody and uphold our core values in work and interactions, both internal and external: Be Purposeful, Be Authentic, Be Brave, Be Positive, Be Respectful, and Be Accountable.
SCOPE OF ROLE
The Director of UM Quality & Delegation oversight will create, oversee and manage the program and team that provides quality oversight of the clinical operations of internal, offshore, and delegated utilization management programs. This role will direct in the hiring and development of their team. Responsibilities include applying deep knowledge of clinical information, regulatory, and accreditation requirements to evaluate, audit the daily and overall operations and programs of delegated UM vendors and/or internal UM teams. In the future, this role may support oversight of care management programs and or oversight of delegated providers.
This position will also oversee a team that handles escalated questions and concerns from Provider Relations and Clinical market-based teams for UM cases that cross internal, offshore, and delegated Vendor partners.
The Manager will work closely with the AVP, Clinical Performance. Director, Utilization Management Operations, and Accreditation and Compliance teams to drive performance on the overall utilization management program operations and performance for delegated vendors and internal service delivery teams.
ROLE RESPONSIBILITIES
The Director, UM Quality and Delegation Oversight job description is intended to point out major responsibilities within the role, but it is not limited to these items.
RESPONSIBILITIES
% OF TIME
1. Lead, develop, report and supervise the daily operations and work of the UM Quality audit staff to ensure Bright, offshore, and delegated UM teams meet accreditation and regulatory standards
30%
2. Build Quality oversight tools and programs that ensure compliance against Accreditation and Regulatory standards, oversee execution of quality audits, and report outcomes of audits.
15%
3. Work with Compliance and Accreditation teams to identify Corrective Actions needed by any team or organization and partner with those teams to ensure quick improvement against quality findings.
15%
4. Lead, develop and manage a process to respond, solution and provide guidance to address any operational questions and/or escalated UM cases from delegates, Care Partners, providers, and internal staff and colleagues.
15%
5. Create and implement policies related to corresponding UM quality program and delegation oversight. Coordinate with UM Operations, Medical Policy, Accreditation, and Regulatory teams to ensure policies are in compliance with Accreditation and Regulatory standards.
10%
6. Identify opportunities for quality and process improvements necessary to facilitate departmental and programmatic functions.
5%
7. Serve as a member of Bright Health’s UM Committee, reporting UM program performance and associated operational updates as well as managed workplans and prioritize resources to meet key deliverables.
5%
8. Support coordination of Bright programs through maintenance and oversight of cross-functional communication and referral procedures with other departments including Clinical Market Performance, Appeals and Grievances, Care Management, Member and Provider Services, Special Services Team, Care Navigation, etc….
5%
SUPERVISORY RESPONSIBILITIES
This position will supervise a team of Quality audit Supervisors, clinicians and non-clinical specialists.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
· A Bachelor’s Degree in business, healthcare administration, nursing, or a related field is required; MBA/MHA and/or clinical degree is preferred
· 5 (five)+ years of utilization management/quality improvement experience.
· Working knowledge and understanding of basic utilization management and quality improvement concepts.
· Previous experience as a manager of a functional area and/or managing cross functional teams on large scale projects.
· Prior experience with highly regulated environment including Federal, State and national accreditation standards preferred.
PROFESSIONAL COMPETENCIES
· Experience with problem management, change control and how to influence change without direct control within a decentralized business unit culture.
· Experience supervising teams with high visibility across products/business capabilities with experience identifying and managing dependencies within and across teams preferred.
· Excellent writing skills, particularly in determination notification writing.
· Ability to develop strong cross-functional and collaborative relationship with internal and external partners, including the ability to work with a wide variety of people and personalities.
· Must be self-motivated, able to take initiative, and ability to thrive and drive results in a collaborative environment.
· Must possess strong organizational and prioritization skills and competence and capacity to handle multiple initiatives while managing conflicting priorities.
· Experience in using the Microsoft Office Suite including Excel and Word as well as demonstrated ability to learn/adapt to other computer-based systems and tools.
LICENSURES AND CERTIFICATIONS
Active, current state’s RN license preferred or other applicable professional licensure/certifications
Certification in Healthcare Compliance (CHC) and/or Certified Compliance & Ethics Professional (CCEP)
WORK ENVIRONMENT
The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Some travel may be required.
EEO/AFFIRMATIVE ACTION STATEMENT
As an Equal Opportunity/Affirmative Action 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.
