VP, Care Management - Medicare will collaborate with clinical leaders to build and implement Care Management Programs that deliver excellent clinical and medical cost outcomes with compliant operations for Bright’s Medicare / Medicare Special Needs Plans line of business.

This role will provide leadership and direction to the Care Management teams and vendors supporting Medicare members. In addition to overseeing internal operations, this role will work closely with Delegated UM organizations and internal delegated oversight teams, to ensure Bright members receive appropriate access to care and coordinated, evidence-based services. The position will be accountable for continuous process optimization and will provide support and leadership in the integration of Bright’s Medicare Care Management teams.

The VP of Care Management – Medicare will be an important part of the Bright Healthcare Clinical Performance leadership team, and work directly with Bright Healthcare’s Medical Directors, Utilization Management, Stars, Quality, and Member Rewards leadership to ensure compliant and high-performing Care Management process and outcomes. This position will also interface regularly with Bright’s Medicare Line of Business, and Market leadership teams to ensure excellent member and provider experience of care across Bright’s various markets.

ROLE RESPONSIBILITIES

1. Build and oversee care management teams and solutions that yield industry-leading medical cost outcomes, excellence in member experience, and efficient administrative cost. Drive continuous improvement in processes and technology development to better serve our members and providers. .
2. Ensure Care Management compliance with all of Bright’s Special Needs Plans Models of Care. Collaborate with Line of Business leadership to regularly update Models of Care to meet member needs.
3. Provide support and leadership in the integration of Bright’s Medicare Care Management teams. Identify internal and industry best practices, technology solution development and optimal team structure, and coordinate with HR, Product/Technology, and other teams to drive execution.
4. Collaborate with Bright’s Medical Directors, Quality, Stars, Member Services, Utilization Management, and Member Rewards teams to establish clinical strategies that enhance program performance and align with Bright’s core objectives, policies and values.
5. Support development and ensure compliance with policies and procedures related to corresponding Care management functions.
6. Participate in and/or lead the implementation of new clinical initiatives and/or new market expansions in relation to care management strategy and Model of Care development.
7. Represent the Care Management functions within Bright Committee structures to report program performance and provide operational updates.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
• Bachelor’s degree in a related field required. An RN or other clinical licensure is preferred, but not required.
• Ten (10) or more years of professional experience, including five (5) years developing and/or managing clinical programs, products and services required.
• At least five (5) years of experience working within a care management or care coordination operation required.
• Prior experience with Care Management of Medicare Special Needs Plans strongly preferred.

PROFESSIONAL COMPETENCIES
• Strong clinical leadership skills to ensure trust and respect of clinical staff
• Strong operational mindset and ability to use data to draw insights
• Strong ability to communicate in written and verbal presentations
• Strong relationship development and team management skills
• Results oriented - capable of clearly translating strategic objectives into implementation plans that drive outcomes
• Success in driving organizational change and performance improvement
• Strong collaboration skills to ensure effective alignment among diverse teams
• Ability to excel in a matrixed environment

LICENSURES AND CERTIFICATIONS
• No licensures and/or certifications are required for this role.

WORK ENVIRONMENT
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.