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Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.

What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.

If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.


 

SCOPE OF ROLE

The Senior Quality Management Nurse, Utilization Management, will be responsible for the development and execution of a quality oversight program focused on Bright’s utilization management program. This position will ensure program policies and procedures meet relevant federal, state and accreditation statutes and standards. They will also coordinate regular monitoring and auditing of workflows. Lastly, the Quality Oversight Manager will be responsible for coordinating the federal and state requests for compliance reporting as well as audits.

ROLE RESPONSIBILITIES

The Senior Quality Management Nurse, Utilization Management job description is intended to point out major responsibilities within the role, but it is not limited to these items.

  • Development and execution of a quality oversight program for a utilization management program regular training, monitoring and audits including communicating status updates, results, and outcomes via written and oral report to internal and external stakeholders.
  • Ensure utilization management program policies and procedures meet all federal and state guidelines as well as URAC accreditation standards as well as be the department resource to ensure understanding of timeliness measures and other regulatory and accreditation UM standards.
  • Coordinate the development of reporting required by state and federal agencies and consulting with the configuration team regarding opportunities to enhance the efficiency and quality for users of the information system to support UM activities.
  • Coordinate and collaborate with the Compliance team in the preparation and execution of state and federal agency audits, including CMS audits. This may include leading mock audits, regular data universe audits and process audits.
  • Identify areas and root causes of operational clinical issues that need corrective action and collaborate with the delivery team on the remediation activities.
  • Ensure entry of data requirements into utilization management platform is consistent, accurate, and appropriate per workflow requirements and documentation standards.
  • Other activities as assigned

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

  • Associate’s degree in Nursing required; Bachelor’s degree preferred
  • Three (3) years of utilization management/quality improvement experience required.
  • Advanced knowledge and understanding of basic utilization management and quality improvement concepts required.
  • Advanced knowledge of CMS, URAC and/or State utilization management statutes and standards required.
  • Previous experience as a lead in a functional area or managing cross functional teams on large scale projects required.
  • Previous experience developing, participating and/or leading audit program and/or process for oversight required.

PROFESSIONAL COMPETENCIES

  • Experience translating complex regulations and standards into policies and procedures.
  • Must be self-motivated, able to take initiative, and ability to thrive and drive results in a collaborative environment.
  • Must possess strong organizational and prioritization skills and competence and capacity to handle multiple initiatives while managing conflicting priorities.
  • Experience with problem management, change control and how to influence change without direct control within a decentralized business unit culture.
  • Excellent writing skills, particularly in determination notification writing.
  • Ability to develop strong cross-functional and collaborative relationship with internal and external partners, including the ability to work with a wide variety of people and personalities.
  • Experience in using the Microsoft Office Suite including Excel and Word as well as demonstrated ability to learn/adapt to other computer-based systems and tools.

LICENSURES AND CERTIFICATIONS

  • An active, unrestricted Registered Nursing (RN), Licensed Practical Nurse (LPN), Licensed Social Worker (LICSW) or Licensed Professional Clinical Counselor (LPCC) license to practice as a health professional in a state or territory of the United States is required for this role.

WORK ENVIRONMENT

  • The majority of work responsibilities are performed in a remote office setting, carrying out detailed work sitting at a desk/table and working on the computer. Travel may be required.
 

We’re Making Healthcare Right. Together.

We are realizing a completely different healthcare experience where payors, providers, doctors, and patients can all feel connected, aligned and unified on the same team. By eradicating the frictions of competing needs, we are making it possible to give everyone more of what they want and deserve. We do this by:
 
Focusing on Consumers
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
 
Building on Alignment
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.
 
Powered by Technology
We employ our purpose built, integrated data platform to connect clinical, financial, and social data, to deliver exceptional outcomes.
 
          

 
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.
 

 

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