ABOUT THE ROLE

The Provider Disputes Manager oversees Bright Health provider payment dispute operations, for all Bright product offerings, to ensure regulatory compliance and operational efficiency. This position is responsible for Bright employees in the processing and resolution of provider payment dispute cases, the accurate response to escalated inquiries and grievances, and oversight of delegates performing appeals and grievances functions on behalf of Bright Health. They are responsible for timely and accurate review of changes in regulatory guidance affecting appeals and grievances operations, evaluating the operational impact of Bright entering new markets, and evaluating the operational impact of Bright increasing the scope of product offerings by market.

YOUR

• Leads, organizes, and directs the activities of the Provider Payment Dispute unit that is responsible for reviewing and resolving provider disputes and communicating resolution to members, providers and authorized representatives in accordance with state and federal law
• Develop and maintain business policies, procedures, workflows, and correspondence materials related to both the state-based Individual and Family Plans (IFPs) and Small Group Appeals and Grievances operations to ensure compliance with state and federal regulations
• Define and maintain Bright’s Provider Dispute process to ensure regulatory compliance and consumer experience
• Create the appropriate business requirement documents for performance monitoring, operational reporting, and regulatory reporting
• Work with internal teams and delegated partners to implement, oversee, and manage any delegated Provider Dispute functions
• Manage the configuration and customization of technology to meet business requirements
• Achieve turn-around time and quality metrics to ensure regulatory compliance and optimal administrative STAR ratings
• Train appeals and grievances staff, customer/member services department, sales, UM, and other departments within Bright Health (and delegates) on early recognition and timely routing of Provider Dispute
• Train and manage Provider Dispute analyst staff to ensure high-quality case resolution of non-delegated, escalated, and regulatory cases
• Maintain systems for tracking appeals and grievances data and manage the completed case repository for regulator audit preparedness
• Manage system permissions for Provider Dispute staff and acquire access to systems needed for the team to complete the team’s work 
• Provide trend analysis to internal or external stakeholders, as necessary, to escalate issues to appropriate organizational decision makers
• Provide internal and regulatory reporting, on a scheduled or ad-hoc basis, to stakeholders as requested
• Serve as primary Provider Dispute contact to internal and external stakeholders
• Handle provider, member, regulator, or other parties-to-a-complaint phone calls that escalate beyond the handling of the Provider Dispute analyst and maintain the highest quality customer service possible

SUPERVISORY RESPONSIBILITIES

• This position has supervisory responsibilities for Provider Dispute team

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree preferred, 10 years insurance experience
• Seven (7) or more years of experience in Appeals and Grievances or Claims
• Four (4) or more years management experience and proven leadership qualities
• Certified Claim Coder preferred

PROFESSIONAL COMPETENCIES

• Detail oriented
• Thrive in a fast-paced environment
• Excels at creating structure and bringing operational rigor to teams; passion for creating an effective team environment and resolving conflicts
• Self-directed and able to prioritize work appropriately and take ownership to drive results
• Ability to develop a cohesive team culture and develop team members

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!