Medical Director, Utilization Management at Bright Health

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ABOUT THIS 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 Arizona 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 (5) 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 among internal and external clinical staff.

PROFESSIONAL COMPETENCIES

  • 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

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!

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Technology we use

  • Engineering
  • Product
    • .NETLanguages
    • C#Languages
    • JavascriptLanguages
    • PythonLanguages
    • SqlLanguages
    • PowerShellLanguages
    • D3JSLibraries
    • ReactLibraries
    • Node.jsFrameworks
    • MongoDBDatabases
    • TSQLDatabases
    • InVisionDesign
    • SketchDesign
    • Lucid ChartDesign
    • JIRAManagement
    • Microsoft ProjectManagement

Location

We are downtown at 515 Congress Avenue, right in the heart of downtown! Tons of restaurants and close to public transportation.

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?

Our team works within an Agile framework with 2 week sprints. Tasks in my sprint that I tackle daily range from ideation, research, designing wires and mocks in Sketch, UI kit updates, prepping for an engineering handoff, etc.

Diane

Digital Product Designer

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

Full Stack Software Engineer

How do you make yourself accessible to the rest of the team?

Modeling after my manager, I like to provide both regularly scheduled one-on-one meetings, where developers and engineers get to set the agenda. We can talk about career development, design and architecture ideas, industry trends, or traditional HR topics like goal setting. It’s up to them. I also have begun setting regular “office hours.”

Amy

VP & Data Platform Architect

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 an open PTO program. We put 3% of your total earnings into your 401K plan and you are immediately vested in that. 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 stand up
Open door policy
Team owned deliverables
Team based strategic planning
Pair programming
Open office floor plan
Diversity
Highly diverse management team
Mean gender pay gap below 10%
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
Onsite Gym
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
Company Equity
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.
Family Medical Leave
Employees who have been with the company for 12 months are eligible for 12 weeks of family medical leave.
Company sponsored family events
Bright Health sponsors family oriented events Annually.
Vacation & Time Off Benefits
Unlimited Vacation Policy
Paid Holidays
Perks & Discounts
Casual Dress
Commuter Benefits
Stocked Kitchen
Happy Hours
Happy hours are hosted on occasion.
Fitness Subsidies
Bright Health employees are eligible for discounts on several gym memberships.
Professional Development Benefits
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