Brighton Health Plan Solutions

Title: Contract Manager Location: Westbury, NY Job Description: About The Role BHPS is seeking a Contract Manager responsible for the contracting and maintenance of the relationship with network health systems in their assigned territory or specialty. This also includes the recruitment, and management of the provider network inclusive of hospitals and physician groups in the New York metro market. The successful candidate will perform all of the requisite due diligence activities to identify and secure new relationships and contracts as needed with providers and re-contract with existing providers to ensure cost effective and competitive arrangements. The Contract Manager will also coordinate with other areas as appropriate to incorporate a sound strategic approach to provider network development. The Contract Manager is a strategic and operationally oriented professional that will help build partnerships with our network, bring an analytic mindset to discussions and manage and execute projects including network development and provider outreach. Success in this position is based on strong communication skills and solid relationships with internal and external stakeholders. *Please note, this position is a hybrid position and can be based in our Long Island office. Primary Responsibilities • Review, analyze, negotiate, implement, and maintain existing contracts with an understanding of professional rate schedules and contractual language. • Identify network development opportunities through financial analysis, client requests, and product development. • Define performance improvement opportunities. • Implement new and evolving strategic contract initiatives including alternative payment methodologies, e.g. bundling, value-based payment, pay for performance. • Analyze reports on cost, utilization, claim submission patterns and outcomes. Prepare presentations on subsequent findings. • Develop, implement, and support the ongoing efforts to build new network solutions and deploy solutions as appropriate. • Assist in resolution of provider issues, including root cause analyses, mediation between parties, and strategic relevance to the organization and its clients. • Partner with different areas for outstanding payments, medical management, and provider policy. • Other duties and projects as assigned and specified by supervisor in line with department and company needs. Essential Qualifications • Minimum 5 years in a provider or hospital administration role. • Strong understanding of contract language. • Strong understanding of professional provider cost structures and reimbursement methodologies. • Sound knowledge of healthcare contracting. • Demonstrated analytical & negotiation abilities, with excellent communication and presentation skills. • Ability to multi-task. • Organized and methodical. • Customer service skills. • Proficiency in Excel. Preferred Qualifications • 5 years in a provider contracting role with existing market relationships. • Experience in financial or actuarial modeling. • Expert proficiency in Excel. • SQL and access experience. • Understanding of provider experience and clinical operations. • Revenue cycle management. • Master’s Degree. 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 of 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. 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]

• Monitor Utilization Management and Case Management activities through the development of KPIs and benchmarks (i.e. member engagement rates, readmissions, preventable hospitalizations, ER utilization) • Develop statistical models that deliver meaningful insights on cost, utilization and clinical outcomes based on various data sources. • Develop algorithms for stratifying populations and identifying high-risk members. • Leverage Predictive Analytics to measure the performance (ROI) of Disease Management and other Medical Management programs. • Conduct prospective savings analyses in support of clinical program initiatives. • Build and maintain client-facing reports, dashboards, and analyses. • Develop actionable data insights and advise on client strategy. • Participate in program performance review presentations with clinical program managers, client account managers, and external clients, as needed. • Manage internal and external client requests and timelines to ensure timely delivery. • Collaborate with Medical Management to provide ongoing support.

• Own the day-to-day client relationship for an assigned book of business (1000+ subscriber accounts) • Lead efforts to ensure client satisfaction, retention, and renewal • Communicate proactively with clients to anticipate needs, provide timely updates, and deliver actionable insights • Coordinate with Operations, Network Management, Analytics, Finance, Marketing, and Customer Service • Develop a deep understanding of each client’s strategic business objectives • Identify, escalate, and resolve issues, ensuring ownership through completion • Advocate for client needs • Leverage data and analytics to deliver insights • Lead the development and execution of strategies to expand client engagement • Maintain and update all client-related activities in Salesforce • Represent Brighton Health at client meetings and industry conferences

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description BHPS provides Utilization Review services to its clients. The UM Denials Coordinator supports the Utilization Management function by reviewing denied and partially denied authorizations and preparing denial correspondence within the Utilization Management system. This role is responsible for drafting, editing, and formatting denial and partial denial letters to ensure clarity, accuracy, completeness, and appropriate readability, while maintaining compliance with regulatory requirements and client-specific service level agreements. The position works closely with physicians and nursing staff and may require follow-up phone calls or email communication to clarify determinations, obtain additional information, or resolve discrepancies prior to letter release. The UM Denials Coordinator reports to the Clinical Services team and performs a range of moderately complex administrative and operational tasks in support of UM activities. This is a fast-paced, productivity-driven role that requires strong attention to detail, sound judgment, and the ability to manage competing priorities. Qualifications - LPN license required. - Two or more years of experience in Utilization Management or medical necessity Appeals. - Strong verbal and written communication skills. - Demonstrated customer service skills, including effective written and verbal communication. - Proficient in Microsoft Office applications, including Word, Excel, and Outlook, in a Windows-based environment. - Ability to adapt quickly to changing business needs and learn new processes and systems. Requirements - Review denied authorization cases within the Utilization Management system to understand the clinical determination and supporting rationale prior to letter creation or finalization. - Draft, edit, and format denial and partial denial letters based on authorization determinations, including creation of member friendly letter language, accurately copying and inserting approved clinical statements, criteria citations, and other information into correspondence templates. - Apply working knowledge of Utilization Management processes and sound judgment to ensure all written correspondence is clear, readable, complete, and accurate. - Ensure all letter content, data fields, and member, provider, and service details are accurately populated to prevent compliance risks or downstream operational issues. - Communicate with physicians and nursing staff as needed to clarify determinations, obtain missing information, or resolve discrepancies prior to letter release. - Prioritize and triage denied authorization cases in alignment with client-specific requirements and regulatory turnaround times. - Respond to and resolve member and provider inquiries related to denied authorizations and denial correspondence. - Responsible for pulling and analyzing reporting around denial processes and presenting analysis to leadership. - Perform other related duties as assigned. Benefits - Previous experience reviewing or writing UM denial letter language. - Proficient/Experienced with CPT4 and ICD-10 codes. - Working knowledge of URAC and NCQA documentation standards.