Medical Director - Determinations

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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 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.

ROLE 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.
  • 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.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
  • Medical Doctor or Doctor of Osteopathy.
  • Board certification in Internal Medicine, Family Practice or other primary care specialty. 
LICENSURES AND CERTIFICATIONS
  • Active, unrestricted license to practice medicine in a state or territory of the United States.
PROFESSIONAL COMPETENCIES
  • 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.
BEHAVIORAL AND LEADERSHIP NORMS
  • 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’re Making Healthcare Right. Together.
We are realizing a completely different healthcare experience where payors, providers, doctors, and patients can all feel connected, aligned and unified on the same team. By eradicating the frictions of competing needs, we are making it possible to give everyone more of what they want and deserve. We do this by:
 
Focusing on Consumers
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
 
Building on Alignment
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.
 
Powered by Technology
We employ our purpose built, integrated data platform to connect clinical, financial, and social data, to deliver exceptional outcomes.
 
          
 
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.
 

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Technology we use

  • Engineering
  • Product
  • Sales & Marketing
    • .NETLanguages
    • C#Languages
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    • JavascriptLanguages
    • PythonLanguages
    • ScalaLanguages
    • SqlLanguages
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    • InVisionDesign
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    • ConfluenceManagement
    • JIRAManagement
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    • Microsoft DynamicsCRM

Location

We are downtown at 515 Congress Avenue, right in the heart of downtown! Tons of restaurants and close to public transportation.
Making Healthcare Better For All At Bright Health
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An Insider's view of Bright Health

What’s the vibe like in the office?

The office has a relaxed and laid back vibe but people are very serious about their work - perfect!

Anthony

Data Engineer

What does your typical day look like?

My day is so varied, given how quickly we're growing, which is fulfilling for me. I have a good balance of strategic and tactical work in my day as well as time to focus and time to collaborate.

Jen

VP, Digital

What makes someone successful on your team?

A hard-working team player who thinks first and codes next is likely to learn a lot and quickly become a valuable member of the team. Lots of experience with some of our tooling is always nice, but if someone can't knowledge-share well or responds poorly to code reviews and other requests for collaboration, it'll be a tough fit.

Brian

Software Engineer 3

How do your team's ideas influence the company's direction?

We hire smart individuals who thrive on accomplishment and purpose. Our teams are exposed to the bigger picture through constant communication and dialogues – that encourages them to come up with innovative solutions to problems. We've made significant adjustments on our direction in technology and process that were initiated by the team.

Abdullah

VP, Engineering

What are Bright Health Perks + Benefits

Bright Health Benefits Overview

We have 3 different health insurance plans, all through Cigna (HDP, Premium HDP and PPO). We cover the majority of the cost for the employee and some cost for family. We have two dental plans and a vision plan as well. We have a Lifestyle Spending Account and options for HSA/FSA. We put 3% of your total earnings into your 401K plan and you are immediately vested. We have all the latest technology (Mac or Surface laptops – your choice) to use including standing desks. Fully stocked fridge with snacks and drinks.

Culture
Friends outside of work
Eat lunch together
Daily sync
Open door policy
Team owned deliverables
Team based strategic planning
Group brainstorming sessions
Pair programming
Open office floor plan
Diversity
Dedicated Diversity/Inclusion Staff
Unconscious bias training
Someone's primary function is managing the company’s diversity and inclusion initiatives
Mean gender pay gap below 10%
Hiring Practices that Promote Diversity
Health Insurance & Wellness Benefits
Flexible Spending Account (FSA)
Bright Health employees can contribute up to $3500 annually to their FSA.
Disability Insurance
Dental Benefits
Vision Benefits
Health Insurance Benefits
Life Insurance
Wellness Programs
Bright Health is proud to offer a wellness stipend of $200/month to all employees!
Onsite Gym
Mental Health Benefits
Retirement & Stock Options Benefits
401(K)
We will put 3% of your total earnings into your 401K plan, even if you don't put anything in. It's a safe harbor contribution.
401(K) Matching
Bright Health provides employees with a 401(k) plan managed by Vanguard. We provide a ‘safe harbor’ non-elective contribution equal to 3% of your compensation, regardless of participation in the p
Performance Bonus
Child Care & Parental Leave Benefits
Generous Parental Leave
We provide up to 6 weeks of parental leave for the primary caretaker. We also provide 2 weeks of leave for the secondary caretaker.
Flexible Work Schedule
Bright Health provides employees with a flexible work schedule that includes Core hours, Flexible start and end times.
Remote Work Program
Family Medical Leave
Company sponsored family events
Bright Health sponsors family oriented events Annually.
Vacation & Time Off Benefits
Generous PTO
Paid Holidays
Paid Sick Days
Perks & Discounts
Casual Dress
Commuter Benefits
Stocked Kitchen
Happy Hours
Happy hours are hosted on occasion.
Relocation Assistance
Fitness Subsidies
Bright Health employees are eligible for discounts on several gym memberships.
Home Office Stipend for Remote Employees
Professional Development Benefits
Diversity Program
Lunch and learns
Cross functional training encouraged
Promote from within
Online course subscriptions available
Customized development tracks

Additional Perks + Benefits

Bright's primary goal is to offer employee benefits and perks that are as flexible as possible to meet each employee's unique needs!

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