ABOUT THE ROLE
This role is responsible for leading the critical function for Bright Health’s products, including commercial Individual and Family Plans (IFP), Medicare Advantage and any future offerings. This role leads both the operational and technical initiatives, which includes management of vendors, implementation of new vendors and overall KPI’s. This position is accountable for ensuring that internal and external service level agreements are met. In addition, this position has ultimate accountability for ensuring that teams comply with all state and federal regulations including those from CMS and multiple state divisions of insurance.
Management of Payment Integrity program is an additional key component of the role. Partner with external vendors and internal Medical Cost Containment team to create and maintain the Bright Payment Integrity program to ensure accurate and transparent billing and payment processes in a cost-effective manner. Partner with claim leadership to review existing payment practices, existing payment policies to ensure Bright is compliant.
Relationship management internally and externally will be key to the Director of Payment Integrity role. Payment Integrity, Medical Cost Management and Claims must be aligned for each team to be considered effective and successful.
- Technical/Operational Leadership
- Strategic/Operational Planning: create, lead and maintain payment integrity program for all Bright Health products.
- Relationship Management: external vendors and internal partners (Risk Adjustment, Finance, etc)
- People Management: supervisory responsibility over the payment integrity team
- Essential Department and Organizational Functions
- This position has supervisory responsibilities for payment integrity operations.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Minimum 10 years health operations experience, including a minimum of 8 years of progressively responsible experience in various functions of Payment Integrity , such as claims editing, enrollment, coordination of benefits, overpayment identification, claims auditing, pharmacy, Fraud, Waste and Abuse, and health care subrogation / third party liability
- Minimum 5 years experience managing people leaders in a payment integrity or operations capacity
- Large scale project oversight experience
- Financial management experience
- Experience with Tableau or Power BI
- Ability to operate within a changing environment
- Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.
- Strong collaboration skills to ensure effective alignment among diverse teams
At Bright Health, we brought together the brightest minds from the health care industry and consumer technology and together we created Bright Health: a new, brighter approach to healthcare, built for individuals. Our plans are easy to manage, personalized and more affordable, giving people the quality care they deserve. Through our exclusive care partnerships with leading health systems in local communities we are reshaping how people and physicians achieve better health together.
We’re Making Healthcare Right. Together.
We've won some fun awards like: Great Places to Work, Modern Healthcare, Forbes, etc. But more than anything, we're a group of people who are really dedicated to our mission in healthcare. Come join our growing team!
As an Equal Opportunity 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.