Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.

What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.

If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.

SCOPE OF ROLE

The Director, Utilization Management, provides leadership for the Utilization Management clinical team.   The Director will lead Utilization Management operations across Bright’s service area, across Bright’s lines of business, and have direct oversight of preauthorization, concurrent, behavioral health, and complex case reviews.   The Director will directly oversee employed clinical staff and managers, and coordinate with offshore clinical staff to ensure members receive timely, high quality and evidence-based care.    This leader will be accountable for driving continuous improvement in quality performance and also administrative cost efficiency of the function.  The Director will apply deep knowledge of regulatory and accreditation requirements to ensure compliance in Utilization Management operations. The Director will work closely with the Care Management, Quality & Accreditation, Delegation oversight and Network-facing leadership teams.

ROLE RESPONSIBILITIES

The Director, Utilization Management job description is intended to point out major responsibilities within the role, but it is not limited to these items.

• Manage the daily operations and production of Utilization Management clinical staff and management. Hire, develop and evaluate staff. Implement corrective actions and termination as needed.
• Oversee daily performance and coordination of offshore and/or delegated clinical staff to ensure quality and productivity goals are consistently met.
• Collaborate with Bright’s Medical Directors to establish clinical strategies and operational processes that enhance program performance and align with Bright’s core objectives, policies and values
• Ensure compliance within applicable Accreditation standards, Federal and State requirements, and line of business service delivery guidelines, including education of staff for consistent compliance to guidelines. Identify and drive remediation or improvement plans as needed.
• Participate in and/or lead the implementation of new clinical initiatives and/or new market installations in relation to utilization management
• Support development and maintenance of policies and procedures related to corresponding utilization management functions
• Coordinate with other leaders of internal and delegated functions at Bright, including care management, care navigation, clinical market teams, claims and line of business leaders, to identify opportunities to improve member and provider experience across programs.

SUPERVISORY RESPONSIBILITIES

This position has supervisory responsibilities for members of the Utilization Management clinical team.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree in a related field required.
• An RN or other clinical licensure is required
• Eight (8) or more years of professional experience, including five (5) years developing and/or managing clinical programs, products
• and services required.
• At least two (2) years of experience working within a utilization management operation required.
• Prior experience with URAC or NCQA accreditation strongly preferred.
• Formal training in Six Sigma management techniques preferred.

PROFESSIONAL COMPETENCIES

• Strong operational mindset and ability to use data to draw insights
• Thrive and drive results in a collaborative environment
• Strong ability to communicate in written and verbal presentations
• Strong team leadership skills

LICENSURES AND CERTIFICATIONS

• RN or other active license in good standing in current state

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. Travel may be required.