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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.
- 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.
- 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
- Build Quality oversight tools and programs that ensure compliance against Accreditation and Regulatory standards, oversee execution of quality audits, and report outcomes of audits.
- 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.
- 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.
- 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.
- Identify opportunities for quality and process improvements necessary to facilitate departmental and programmatic functions.
- 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.
- 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.
- This position will supervise a team of Quality audit Supervisors, clinicians and non-clinical specialists.
- 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.
- 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.
- 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.
- 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)
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.