ABOUT THE ROLE
This role leads Clinical Market Performance Operations across all Bright Health markets in Florida. This individual manages a geographically dispersed market-based team of regional and local clinical market nurses, clinical consultants, and quality nurses. The Director, Clinical Market Performance is responsible for establishing and maintaining working relationships with Care Partner (health care provider) clinical leadership and is accountable for the deployment and scaling of clinical operations including quality gaps, risk adjustment, and clinical program governance – based on Care Partner programs. This individual is also accountable for key results, such as utilization, network keepage, accurate risk adjustment, and quality. In addition to market duties, this role has oversight over utilization management, training, and clinical competencies for all clinical roles in the Clinical Market Performance team.
- Lead market-level utilization management work across the Clinical Market Performance team. Advise nurses on handling utilization management issues, as they arise.
- Design training curriculum for clinical roles across Clinical Market Performance team in accordance with company needs and appropriate clinical competencies. Ensure clinical competencies uniquely position Clinical Market Performance nurses to meet the needs of the market, care partners, members, and the company.
- Represent Clinical Market Performance team in cross-departmental medical policy discussion in accordance with broader clinical strategy.
- Engage Care Partners to effectively achieve clinical performance goals using continuous innovation and improvement through dynamic leadership.
- Launch and sustain clinical operations in new markets, including establishment of market-specific clinical roadmaps with Care Partners that span the functions of health optimization (population health management, quality, coding performance, accreditation, pharmacy management, and data and analytics).
- Build an in-depth understanding of internal and external tools and reports available to you and the regional team to orchestrate a coordinated workflow that equally prioritizes the care of the member, Bright Health’s mission, and the care partner.
- Oversee referral of members to utilization management and care management while providing collaborative support to market team/care partner on strategies to improve these processes.
- Oversee surveillance of high-risk members, tracking, and trending outcomes of care management/complex care management (CM/CCM) activities.
- Support quality and risk process by working with internal teams and collaborating with care partner to request, review, and abstract medical records for HEDIS, quality of care concerns, quality improvement programs, and care coordination, including electronic and paper medical records.
- Thoroughly understand and organize market performance operations to effectively design and apply our collective intervention set, meet utilization, keepage, quality and risk targets, monitor and report our performance, and advance and enhance programs.
- Manage a team of nurses and clinical consultants (analysts) across geographies. This includes working with nurses to ensure competencies and productivity targets are met and that nurses are working efficiently at the top of their licenses.
- Build innovative programs through interaction and collaboration with Care Partner clinical leaders, which requires detailed knowledge of health systems, clinically integrated networks, advanced primary care groups, and risk contracts.
- Regularly revise strategy and tactics to address market needs.
- Convene and lead cross functional teams to mobilize resources within Bright and Care Partners to address issues and to develop processes/relationships.
- Design and deploy a network optimization approach, in concert with Network and Analytics teams.
- Work cross functionally to represent the clinical market perspective in design and deployment of non-clinical programs.
- Lead STARs/quality improvement efforts in the Region.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor’s degree in nursing or related field and current license to practice as a nurse
- An advanced degree such as a Master of Business Administration (MBA), Master of Health Administration (MHA), Master of Public Health (MPH), or equivalent degree is preferred.
- Seven (7) or more years of leadership experience managing care management and quality improvement nurses in payor or provider organizations is required
- Seven (7) or more years of experience with clinical operations, strategy, services, and/or operations in an integrated delivery system or clinically integrated network is required
- Experience in value-based care, population health, quality, coding, training, utilization management, and/or health care analytics is required
- Highly organized and process driven
- Ability to manage teams across geographical locations
- Comfortable delivering professional presentations to an audience
- Exceptional communication skills and will thrive when asked to deliver our unique and differentiated value proposition
- Proficient in the use of Microsoft Office applications including Outlook, Word, Excel, and PowerPoint
LICENSURES AND CERTIFICATIONS
- Current license to practice as a nurse is required.
- This position has responsibility for supervising a team of nurses and clinical consultants.
- Most work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
- Videoconferencing is used frequently.
- Travel is required.
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
, 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.