“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.

ABOUT THE ROLE

The Chief Medical Officer for Medicare Advantage is responsible for three major areas: 1) overseeing the clinical teams that operate within MA Clinical Programs and Operations and establishing a clear strategy and direction for their work; 2) in concert with the Clinical Market Performance team establish effective external relationships with health system physician leaders focused on establishing and executing against market population health, risk, and quality targets, and 3) direct oversight and leadership of Utilization Management. The CMO will also support the Chief Operating Officer of MA in STARs/HEDIS and Risk Adjustment strategy and execution.

YOUR RESPONSIBILITIES

• Establish the strategy for population management for the Medicare Advantage line of business in each market
• Support development of the tenets of our overarching population health, risk adjustment, and quality/Stars strategies at Bright Health
• Represent Bright Health externally at selected conferences, in key professional bodies, with Care Partner clinical and other executive leadership, with media and in other venues
• Establish the strategy and oversee the medical functions of the utilization review/management and quality assurance including the technology, teams, and reporting for these functions
• Build and manage a team of clinical experts to ensure effective population health management and Care Partner interactions in collaboration with the Clinical Market Performance team
• Lead Bright Health’s clinical staff; recruit and assist in the recruitment of key clinical staff
• Support population health staff to ensure timely and consistent responses to members and Care Partners
• Act as lead clinical liaison to network providers and facilities to support the effective execution of population health, risk adjustment, and quality/Stars programs
• Provide oversight and business direction for the following activities, including but not limited to:
• Formulary development
• Pharmacy and Therapeutics management
• Credentialing
• Utilization Management
• Clinical Compliance
• Quality Management and Programs
• Risk Accounting Programs
• Appeals and Grievances Review
• Network Management and Evolution
• Provider Relations
• Market-level clinical management and program development
• Provides clinical consultation to departments throughout and outside the Medicare Advantage organization, including:
• Network
• Operations
• Customer Experience
• Care Partner Integration
• Marketing
• Communications
• Participate in the establishment of path-to-value activities with Care Partners leading to advance value based payment models
• Oversee clinical teams and vendors in partnership with the Population Health Operations team to ensure timeliness in meeting all required Federal and State turnaround time on clinical decision making, including but not limited to: decision reviews that must occur within 6 hours on occasion as demanded by state and federal guidelines, and the ability to participate in second review of group decision must often occur in 24 hours
• Periodically consults with other practitioners in the field

SUPERVISORY RESPONSIBILITIES

• This position has supervisory responsibilities for the all Medicare Advantage Medical Directors

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree required; Master of Public Health (MPH), Master of Health Administration (MHA) or Master of Business Administration (MBA) is preferred
• Ten (10) or more years of experience in Clinical Practice and/or Health Care Industry is required
• Ten (10) or more years of direct clinical care in private and/or academic practice that includes oversight of direct patient care is required
• Post-graduate experience in direct patient care is required
• Previous leadership experience in a clinical oversight role is required
• Previous Medicare and/or Commercial insurance industry experience preferred

PROFESSIONAL COMPETENCIES

• Ability to meet all required Federal and State turnaround time on clinical decision making, including but not limited to; decision reviews that must occur within 6 hours on occasion as demanded by state and federal guidelines
• Ability to participate in second review of group decision must often occur within 24 hours
• Demonstrated knowledge of established medical management and clinical services
• Strong interpersonal and communication skills
• Commitment to carrying out professional responsibilities and an adherence to ethical principles

LICENSURES AND CERTIFICATIONS

• An active, unrestricted MD or DO license in the state of practice or operation is required; MD or DO US Board certification (specialty certifications acceptable) from the appropriate medical licensing board is preferred

ABOUT US

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 Modern Healthcare and Forbes, etc. But more than anything, we're a group of people who are really dedicated to our mission in healthcare. Come join our 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.

BRIGHT ON!