ABOUT THIS ROLE

Our Operations Team ensures that we have the right infrastructure in place to support our corporate offices, Care Partners and Members and Brokers.

The Director, Medicare Advantage Claims and Configuration, will collaborate on an end to end basis with cross functional BHP departments, vendors and other constituents to support the accurate, timely, compliant and efficient processing of claims along with effective follow up on service issues that impact provider and member satisfaction. Additionally, this position will have oversight over the BMS (claims) and BRC (Configuration) relationships and will be responsible for the accuracy of overall configuration and timeliness of claim payments. 

ROLE RESPONSIBILITIES

• Lead the develop of Bright’s Medicare Advantage (MAPD) Claims and Configuration core competency both in terms of internal execution and necessary oversight and collaboration with applicable vendors.
• Develop and maintain business policies consistent with regulatory requirements.
• Create or when necessary, collaborate with internal and external resources to create process flows, procedures, and materials (including member communications) to support claim administration and configuration.
• Develop the appropriate requirements for performance monitoring and reporting at market corporate level, both for internal and CMS needs. Monitoring includes oversight of service level contractual requirements, end to end key performance indicators impacting timely, accurate and cost-effective claims payment, CMS performance metrics and defect related statistics.
• Participate in CMS and other audits. Representing the BHP Claims and Configuration functions. Ensure timely submission of requested documents and data.
• Collaborate with vendors and internal BHP resources to ensure proper system setup and configuration. Manage the configuration and customization of technology to meet business requirements.
• Oversee the performance of these functions as performed by internal and delegated teams.
• Seek ways to achieve continued process improvement to the member and provider experience focusing on quality, timeliness and administrative cost effectiveness. Collaborate with others to create positive points of differentiation pertaining to claims administration.
• Work effectively on occasional or seasonal projects, either as lead or in collaboration with others that support claims administration or wider BHP objectives.
• Work with internal resources and vendors to create thorough, cost justified system enhancements that enhance the effectiveness of claims administration.
• Implement effective quality control and audit programs along with necessary reporting that verifies transaction accuracy and identifies error trends, defects and process improvement opportunities.
• Create necessary daily/weekly/monthly operational reporting in manner that provides the wider organization key day and insight as to the state of claim operations.
• Other duties and responsibilities as assigned.

SUPERVISORY RESPONSIBILITIES

• This position has supervisory responsibility 

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree preferred; Ten (10) or more years of related experience required in lieu of a degree
• Eight (8) or more years of experience in health insurance operations and Medicare Advantage products.
• Five (5) or more years of experience managing a team
• QNXT Claims and Configuration experience and knowledge of Cognizant products highly preferred

PROFESSIONAL COMPETENCIES

• Detail oriented
• Thrive in fast-paced environments
• Excel at creating structure and bringing operational rigor to teams
• Passion for creating an effective team environment and resolving conflicts
• Self-directed and prioritize well
• Excited to take ownership at early stage of company

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. 

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: 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.

BRIGHT ON!