ABOUT THE ROLE

The Medical Director actively uses their medical background, experience, and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. They support peer to peer communication for determinations, appeals and payment disputes. They support and share expertise with the care management team, and report to committee meetings. They recommend and help right policies and procedures in support of improvement in utilization management.

YOUR RESPONSIBILITIES

• Provides medical leadership for utilization management, cost containment, and clinical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services
• Engages in peer to peer conversations to guide and support deliver of evidence based care. This includes review of complex, controversial or experimental medical services
• Facilitates planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care
• Participates in telephonic outreach for collaboration with treating providers. This will include discussion of evidence - based guidelines, opportunities to close clinical quality / service gaps, and care plan changes that can impact health care expenses

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Medical Doctor or Doctor of Osteopathy
• Board certification in Internal Medicine, Family Practice or other primary care specialty
• Active, unrestricted license to practice medicine in a state or territory of the United States. Licensure in North Carolina and Illinois preferred
• This position requires strong clinical knowledge to support review for medically appropriate utilization of medical services and case management with a minimum of five years of clinical practice
• Administrative or managed care experience is highly desirable
• This position requires strong interpersonal skills to generate collaboration and enable independent decision making amongst internal and external clinical staff

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!