Manager, Clinical Performance - Appeals at Bright Health
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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.
SCOPE OF ROLE
The Clinical Manager, Utilization Management, will oversee daily operations of Bright Health’s Utilization Management (UM) clinical staff. This role will be active in the hiring and development of their team. Responsibilities include applying deep knowledge of clinical information and regulatory requirements to daily operations. The Supervisor will work closely with the Director, Utilization Management to drive performance on the UM team.
The Clinical Manager, Utilization Management job description is intended to point out major responsibilities within the role, but it is not limited to these items.
- Supervise the daily operations and production of UM staff and Ensure appropriate usage of resources in order to facilitate the UM process
- Ensure appropriate usage of resources in order to facilitate the UM process
- 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
- Assist with the hiring, development and evaluation of UM staff including corrective actions and terminating as needed
- Evaluate compliance policies and procedures and recommend enhancements
- Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements
- Identify opportunities for quality and process improvements necessary to facilitate department functions
- Educate staff as necessary to ensure consistent performance and adhere to standards
- Support coordination of Bright programs through maintenance and oversight of cross-functional communication and referral procedures
- Other tasks as assigned
- This position will supervise a team of Utilization Management clinicians.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor’s or Associates degree in Nursing required.
- 3 (three)+ years of utilization management/quality improvement experience.
- Working knowledge and understanding of basic utilization management and quality improvement concepts.
- Previous experience as a lead in a functional area 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.
LICENSURES AND CERTIFICATIONS
- An active, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license to practice as a health professional in a state or territory of the United States is required for this role.
- 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.
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.