MagnaCare
Overview
Brighton Health Plan Solutions, LLC is seeking a full-time dynamic clinical leader to provide leadership, oversight and accountability for Clinical Services and Casualty departments. In partnership with the CMO, the VP of Clinical Operations will serve as a key stakeholder and driver for delivering quality-driven, clinically effective and cost-efficient services. The role encompasses design and implementation of department processes and services to meet the needs of commercial and workers’ compensation self-funded clients. The VP will oversee the Casualty and Clinical Services departments, including Utilization Management, Case Management and Population Health. The position can be remote or on-site in New York or New Jersey.
Responsibilities
Oversee all Clinical Services (CS) functions (prior authorization, concurrent review, appeals, case management, disease management, population health) per defined Client agreements through governance and performance monitoring.
Oversee all Workers’ Compensation (WC) Case Management and Utilization Review (UR) Programs through governance and performance monitoring.
Collaborate with the Chief Medical Officer on evaluation of departmental policies and procedures to ensure continuous process and quality improvement.
Develop and drive metrics leading to process improvement and staff accountability.
Ensure compliance with all regulatory requirements pertaining to CS (ERISA, HIPAA confidentiality).
Ensure compliance with all regulatory requirements pertaining to WC (NYS WC, ADR Programs, WC Certified PPO Programs).
Coordinate and participate in WC State Reporting and CS URAC/regulatory audits.
Assist CMO in creating and managing work plans, program descriptions, policies and procedures for URAC accreditation, NCQA readiness/accreditation and other regulatory requirements; maintain departmental audit readiness.
Assist CMO in driving high-cost and payment integrity initiatives for CS and WC in partnership with Finance, Network, Customer Service, Operations and other departments.
Participate in internal/external departmental and inter-departmental meetings relevant to core requirements.
Implement new integrated programs to meet Client requests; work with CMO to set goals and coordinate internal departments and external vendors as needed.
Assist CMO with preparation of Client presentations and RFI/RFP materials.
Lead implementation projects and serve as a liaison between internal and external stakeholders for new Clients.
Discuss and document concerns or issues with the Chief Medical Officer.
Communicate with direct reports through scheduled quarterly performance conversations, Ad Hoc 1:1 meetings and huddles.
Assess training needs, arrange for staff training, and develop reporting that meets auditing standards.
Encourage and support staff toward performance excellence; conduct quarterly assessments and provide constructive feedback.
Act as a subject matter expert and role model for staff, maintaining a positive work environment and professional relationships with clients and vendors.
Essential Qualifications
Currently licensed Registered Nurse (RN), Nurse Practitioner (NP), or Physician Assistant (PA) with appropriate licensure; must maintain current licensure and relevant certifications.
Minimum of 4 years’ experience in a clinical environment.
Strong skills in management of a clinical team.
Previous Utilization Management experience required.
Previous Case Management experience preferred.
Previous Workers’ Compensation experience preferred.
Ability to articulate business case to support management initiatives and influence outcomes.
Approachable, positive demeanor with hands-on and team-focused work style; collaborative across a company with conflict resolution and team-building abilities.
Knowledge of diverse business functions and performance/operation metrics; ability to define and solve problems, collect data, and make effective decisions.
Proficient computer skills (Word, Excel); database experience is a plus.
General knowledge of HIPAA confidentiality laws.
About Brighton Health Plan Solutions, LLC focuses on improving how healthcare is accessed and delivered. The company values diversity, inclusion, and belonging, encouraging everyone to bring their authentic selves to work. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers and other TPAs to solve today’s healthcare challenges with innovative technology and services.
Company Information Company mission: Transform the health plan experience by delivering outstanding products and services to partners. Company vision: Redefine healthcare quality and value by aligning incentives with partners. DEI purpose: Foster a culture of diversity, inclusion and belonging.
Equal Opportunity We are an Equal Opportunity Employer.
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Responsibilities
Oversee all Clinical Services (CS) functions (prior authorization, concurrent review, appeals, case management, disease management, population health) per defined Client agreements through governance and performance monitoring.
Oversee all Workers’ Compensation (WC) Case Management and Utilization Review (UR) Programs through governance and performance monitoring.
Collaborate with the Chief Medical Officer on evaluation of departmental policies and procedures to ensure continuous process and quality improvement.
Develop and drive metrics leading to process improvement and staff accountability.
Ensure compliance with all regulatory requirements pertaining to CS (ERISA, HIPAA confidentiality).
Ensure compliance with all regulatory requirements pertaining to WC (NYS WC, ADR Programs, WC Certified PPO Programs).
Coordinate and participate in WC State Reporting and CS URAC/regulatory audits.
Assist CMO in creating and managing work plans, program descriptions, policies and procedures for URAC accreditation, NCQA readiness/accreditation and other regulatory requirements; maintain departmental audit readiness.
Assist CMO in driving high-cost and payment integrity initiatives for CS and WC in partnership with Finance, Network, Customer Service, Operations and other departments.
Participate in internal/external departmental and inter-departmental meetings relevant to core requirements.
Implement new integrated programs to meet Client requests; work with CMO to set goals and coordinate internal departments and external vendors as needed.
Assist CMO with preparation of Client presentations and RFI/RFP materials.
Lead implementation projects and serve as a liaison between internal and external stakeholders for new Clients.
Discuss and document concerns or issues with the Chief Medical Officer.
Communicate with direct reports through scheduled quarterly performance conversations, Ad Hoc 1:1 meetings and huddles.
Assess training needs, arrange for staff training, and develop reporting that meets auditing standards.
Encourage and support staff toward performance excellence; conduct quarterly assessments and provide constructive feedback.
Act as a subject matter expert and role model for staff, maintaining a positive work environment and professional relationships with clients and vendors.
Essential Qualifications
Currently licensed Registered Nurse (RN), Nurse Practitioner (NP), or Physician Assistant (PA) with appropriate licensure; must maintain current licensure and relevant certifications.
Minimum of 4 years’ experience in a clinical environment.
Strong skills in management of a clinical team.
Previous Utilization Management experience required.
Previous Case Management experience preferred.
Previous Workers’ Compensation experience preferred.
Ability to articulate business case to support management initiatives and influence outcomes.
Approachable, positive demeanor with hands-on and team-focused work style; collaborative across a company with conflict resolution and team-building abilities.
Knowledge of diverse business functions and performance/operation metrics; ability to define and solve problems, collect data, and make effective decisions.
Proficient computer skills (Word, Excel); database experience is a plus.
General knowledge of HIPAA confidentiality laws.
About Brighton Health Plan Solutions, LLC focuses on improving how healthcare is accessed and delivered. The company values diversity, inclusion, and belonging, encouraging everyone to bring their authentic selves to work. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers and other TPAs to solve today’s healthcare challenges with innovative technology and services.
Company Information Company mission: Transform the health plan experience by delivering outstanding products and services to partners. Company vision: Redefine healthcare quality and value by aligning incentives with partners. DEI purpose: Foster a culture of diversity, inclusion and belonging.
Equal Opportunity We are an Equal Opportunity Employer.
#J-18808-Ljbffr