VP, Clinical Services

VP Of Clinical Operations

Brighton Health Plan Solutions, a full-service health plan administrator is looking for a full-time dynamic clinical leader who will provide leadership, oversight and accountability for our Clinical Services and Casualty departments. In partnership with the CMO, the VP of Clinical Operations role will serve as a key stakeholder, decision maker and catalyst for achieving corporate goals through delivery of quality driven, clinically effective and cost-effective services. This role will be responsible in design and implementation of the department's processes and services that meet the needs of our commercial and worker's compensation self-funded clients. The VP needs to have a passion to make healthcare more effective and affordable and will be responsible for the Casualty and Clinical Services departments which in turn includes Utilization Management, Case Management and Population Health divisions. The position can be remote, or on-site our New York or New Jersey.

Primary Responsibilities :

• Through governance and performance monitoring, oversees 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, oversees all Workers' Compensation (WC) Case Management and Utilization Review (UR) Programs.
• Collaborates with the Chief Medical Officer on evaluation of departmental policies and procedures to ensure continuous process and quality improvement within the Department.
• Develops and drives metrics leading to process improvement and staff accountability.
• Is knowledgeable of, adheres to and enforces compliance with all regulatory and statutory regulations that pertain to CS, especially ERISA and HIPAA confidentiality requirements.
• Is knowledgeable of, adheres to and enforces compliance with all regulatory and statutory regulations that pertain to WC, especially NYS Workers' Compensation, NYS WC Alternate Dispute Resolution (ADR) Programs, and WC Certified PPO Programs.
• Coordinates and participates in all WC State Reporting and CS URAC / regulatory audits.
• Assists CMO in creating and managing work plans, program descriptions, policies and procedures required for URAC accreditation, NCQA readiness / accreditation and other regulatory requirements and to maintain departmental audit readiness.
• Assists CMO in driving high-cost initiatives and payment integrity initiatives for CS and WC departments through strong partnership with Finance, Network, Customer Service, Operations and other departments.
• Participates in internal / external departmental and inter-departmental meetings relevant to core requirements.
• Implements new integrated programs as needed to meet Client requests and work with CMO to set goals, engage internal departments and external vendors as needed.
• Assists CMO with preparation of Client presentations and RFI / RFP presentation materials.
• Participates in implementation projects including leading work streams and serving as a liaison between internal and external stakeholders for new Clients.
• Discusses and documents any concerns, complaints and / or issues with Chief Medical Officer.
• Effectively communicates with direct reports through scheduled quarterly performance conversations and Ad Hoc 1 : 1 meetings as well as huddles.
• Evaluates needs for alternative training and assessment of staff. Arrange for staff and training, establishing requirements for goals and developing reporting that meet auditing standards.
• Encourages and supports each staff member in their drive towards performance excellence and assesses staff quarterly and provides constructive and impactful feedback.
• Serves as a subject matter expert and role model for staff, demonstrating quality customer service and consistently maintaining a positive work environment.
• Maintains professional and productive relationships will all clients and vendors.
• Coordinates and participates in all WC State Reporting and audits.

Essential Qualifications :