• Creates and updates medical policies and procedures in conjunction with associate medical directors and other clinical staff and assures consistency and compliance with generally accepted medical standards and guidelines.
• Provides clinical support for all areas of Clinical Services.
• Review medical files and make coverage and medical necessity determinations using good judgement combined with 3rd party and proprietary medical guidelines. 
• Identify, critique, and utilize criteria and resources such as national, state, and professional association guidelines and peer reviewed literature to support sound and objective decision making and rationales in reviews.
• Advises team nurses on appropriateness of care and services through the care continuum including hospitals, skilled nursing facilities, and home care to ensure quality, cost-efficiency and continuity of care; Informs the UR Nurse of certification decisions within appropriate time frames as guided by URAC, ERISA or state regulations.
• Supports training of the nurses and coordinator to improve their knowledge, independence, and understanding.
• Serves as medical expert for care management and population health; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for acceptable medical care.
• Reviews and resolves retro reviews, appeals and grievances related to medical quality of care and actively participates in the functioning of the plan’s grievance and appeals processes.
• Along with the nurse supervisor and manager identify opportunities for improvement and collaborate to enhance team performance. 
• Makes appropriate outreach to community and academic based treating providers wanting to discuss cases.
• Interacts telephonically and personally with employees/departments in order to maintain effective communication and support for and among departments, as well as a positive work atmosphere.
• Opportunity to interact with sales and account management supporting client needs.
• Collaborates with other departments i.e. Member Services, Provider Services, Claims and Contracting, to improve performance.
• Attends departmental committees as assigned.
• Performs other duties as required by the business.
• Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job.

• Board certification in Internal Medicine or an Internal Medicine subspecialty.
• Prior experience in a self-funded commercial or TPA environment.
• Experience serving as a physician lead through a URAC or NCQA accreditation survey or a client delegation audit.
• Certified Physician Executive (CPE) or comparable physician-leadership credential.
• MBA, MHA, or comparable advanced management degree.
• Formal MCG training or MCG vendor certification in criteria application.
• Teaching, faculty, or formal curriculum development experience.
• Experience evaluating or deploying AI-enabled clinical review, criteria automation, or clinical decision-support tooling.
• Multi-state medical licensure and DEA registration.

About
At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.
Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.
Come be a part of the Brightest Ideas in Healthcare™.

Company Mission
Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision
Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

DEI Purpose Statement 
At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities.   We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace.  We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.

*We are an Equal Opportunity Employer

JOB ALERT FRAUD:  We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information.  Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section.  If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: [email protected]