The Vice President of Utilization Management (UM) Operations - Medicare is responsible for providing leadership and direction for onshore and offshore, and delegated clinical and operational staff to ensure consistent, efficient and impactful delivery of utilization management programs for Bright Health Care’s Medicare populations.

This role will provide leadership and direction to the UM operation and direct leadership over the following functions: Intake, Precertification/Predetermination, Concurrent Review, and will support Clinical Appeals. 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 UM teams.

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

ROLE RESPONSIBILITIES

1. Build and oversee Utilization Management teams and programs that yield industry-leading medical cost outcomes, excellence in provider experience, and efficient administrative cost. Oversee compliance and performance of vendor and provider UM delegates, in collaboration with Delegation Oversight teams. Drive continuous improvement in processes and technology development to better serve our members and providers. Develop and hire a strong team of clinical and operational leaders. 
2. Develop, update, and regularly communicate metrics that measure operational and outcomes-oriented performance of the Utilization Management function. Collaborate with finance, market, and analytic teams to develop programs and track outcomes against medical cost targets. Interact with delegated groups, providers, and facilities regarding utilization management performance or issues. 
3. Ensure Utilization Management compliance with CMS guidelines. Create the culture, systems, and processes that support consistent audit-readiness. Develop and oversee implementation of Corrective Action Plans as needed. 
4. Provide support and leadership in the integration of Bright’s Medicare Utilization 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. 
5. Collaborate with Bright’s Medical Directors, Care Management, Claims, Appeals, and Provider Relations teams to establish clinical strategies that enhance program performance and align with Bright’s core objectives, policies and values 
6. Represent the Utilization Management functions within Bright Committee structures to report program performance and provide operational updates. Support development and ensure compliance with policies and procedures related to corresponding Utilization Management functions 

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
• A Bachelor’s Degree in business, healthcare administration, nursing, or a related field is required; MBA/MHA and/or clinical degree is preferred.
• Minimum of ten (10) years of health plan operations experience, with at least five (5) years in a national/regional management role required.
• At least five (5) years of experience in Utilization Management at a health plan required.
• Prior experience with Utilization Management within Medicare strongly preferred.
• Prior experience with overseeing Delegation of Utilization Management 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

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 will be required.