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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 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.
- 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.
- Review determinations for medical necessity
- Support peer to peer conversations for authorization, appeal and concurrent review
- Participate in reviews of utilization by line of business and market
- Report to committees and participate in policy and process improvement
- Support care management and care coordination for members and improve outcomes
- 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.
- This position does not have supervisor responsibilities.
- 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.
- 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.
- Bright Values: Lives the Bright Values. Leads by example. Is viewed as an emerging leader in the company. Acts with quiet, calm determination. Effectively influences inside of the organization.
- Decision making: Drives strong decision making at a functional level. Is capable of taking a large sum of information, and drilling into what is important. Understands organizational impact of decisions and communicates effectively throughout the decision-making process. Pushes issues to resolution.
- Delivers Results: Is results oriented. Is capable of deciphering priorities for self and for others, and focuses the group on what must be done today, and who must do what. Is capable of clearly translating strategic objectives into implementable processes that drive outcomes. Focuses on results, not effort, and is able to efficiently direct time and energy to achieving intended outcome. Can successfully develop a budget and achieve it without sacrificing quality of output. Achieves strong results within their functional area. Has an excellent track record of achieving expected results. Understands how to operate in collaborative framework.
- Direct and Indirect Management: Demonstrates leadership skills. Has mastered autonomous work, and is able to successfully influence direct and indirect teams to achieve goals. Organizes people and resources toward the effective and pursuit of objectives: this includes hiring, firing, efficient supervising and performance appraisals. Delivers thoughtful and constructive feedback to teams, and actively works to develop those around them. Sets an example for our employees. Manages up appropriately and knows how and when to escalate an issue or situation to more senior manager.
- Planning and Execution: Identifies need for planning and has skills to develop, implement, monitor and achieve plans. Knows how and when to adjust plan. Leads others in this effort. Hold self and team accountable for effective planning and execution. Overcomes hurdles.
- Presence: Internally, leads large and small groups of people in meetings. Capable of developing thoughtful agenda, setting objectives, driving clarity of purpose and delivering the intended results. Instills confidence.
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.