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Job DescriptionAbout The Role The Medical Director will be responsible in providing support to our commercial and worker’s compensation self-funded clients seeking cost effective resolution of their member’s claims. Your interest and help leading and developing our team and maturing the program only makes the opportunity more rewarding. We have been in business for 25 years and leading by example you will help create a culture focused on service, support of quality healthcare service, and medical cost containment for the benefit of our clients and their members. Primary Responsibilities • 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.Essential Qualifications, • Board certified with an excellent understanding of the utilization and case management process., • 3 years’ experience working in a managed care environment supporting utilization management and case review with medical necessity determinations., • Case management and / or Population Health Management desirable., • 3 + years of prior clinical practice in either an office or hospital-based setting with boards from any of a wide range of Internal Medicine specialties so long as you are self-motivated to stay up to date on a broad range of medical services using resources such as mcg guidelines, specialty society guidelines, Up-To-Date and other resources to analyze existing cases., • Specialty training in addition to a first board certification highly desirable., • Current, unrestricted clinical license(s)., • Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties, in Internal Medicine or Pediatrics or a subspecialty of Internal Medicine or Pediatrics, is required for MD or DO reviewer., • Ability to communicate clearly and concisely, both verbally and in writing., • Knowledge of evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions., • Good interpersonal and communication skills to support the team approach., • Ability to work proficiently on a computer and knowledge of basic programs. 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. Annual Salary Range: $200,000-$235,000 -bonus eligible The salary range and/or hourly rate listed is a good faith determination that may be offered to a successful applicant for this position at the time of the posting of an advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable by law including but not limited to location, years of relevant experience, education, credentials, skills, budget and internal equity. *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: recruiting@brightonhps.com Powered by JazzHR zFF9s2Wbxk

Job DescriptionCompany Description About AbbVie AbbVie's mission is to discover and deliver innovative medicines and solutions that solve serious health issues today and address the medical challenges of tomorrow. We strive to have a remarkable impact on people's lives across several key therapeutic areas including immunology, oncology and neuroscience - and products and services in our Allergan Aesthetics portfolio. For more information about AbbVie, please visit us at www.abbvie.com. Follow @abbvie on LinkedIn, Facebook, Instagram, X and YouTube. Job Description This role is field-based, and candidates should live within a reasonable distance from the primary city. Talent will be hired at a level commensurate with experience. Execute brand strategy and tactics in field, sales performance, effectively manage assigned territory and targeted accounts, build strong customer relationships and customer needs solving capability to maximize short and long term sales performance placing the patient into the center of any efforts and operating within AbbVie’s business code of conduct, policies and all applicable laws and regulations. Responsibilities • Deliver sales performance, brand KPIs, financial targets, marketing objectives, etc. to meet or exceed on those objectives., • Create pre-call plan objectives and execute post-call evaluation to continuously improve sales performance. Effectively handle objections, misunderstandings, concerns and consistently gain logical and reasonable calls to action to close on every sales call., • Proactively and continuously aspire to serve customer needs, customer expectations and challenges to build trusted customer relationships and to achieve win-win agreements between AbbVie and customers, • Develop and execute a call plan that achieves set call metrics and optimizes coverage and frequency to key customers to maximize access and sales opportunities., • Continuously build understanding on customer needs and expectations, territory market landscape, competitors, market segments/dynamics, accounts, disease, product, clinical and sales expertise and share this market intelligence information with in-field team, brand team and sales manager to achieve alignment, to anticipate environmental changes and challenges and to optimize brand strategy and its execution., • Differentiate AbbVie’s value proposition with health providers assigned and identify, develop, and maintain disease state experts and speakers/advocates to maximize brand performanceQualifications, • Bachelor’s degree in health, sciences, pharmacy or business-related field preferred or relevant and equivalent industry experience required, • Relevant and equivalent industry experience required in lieu of a bachelor’s degree is at least five (5) years of experience with three (3) or more years of experience within the pharmaceutical/health/science industry preferred and a high school diploma/GED required, • Proven track record of leadership success and solid presentation skills. Strong business acumen and proficient use of business tools; possesses strategic and critical thinking capabilities., • Proactively identifies customer style / behavior and adapts quickly all aspects of selling approach. Operates effectively in a matrix environment., • Preferred: Proven track record of success in sales performance within respective therapeutic areas., • Preferred: Commercial pharmaceutical industry experiences such as physician/account based selling, training, managed health care or marketing preferred., • Preferred: Demonstrates in-depth scientific, therapeutic, product, and competitive knowledge and is recognized as an expert resource by all relevant stakeholders, • Preferred: English language proficiency verbally and in writing (for all non-English speaking countries)., • An essential requirement of your position is to satisfy all applicable health care industry representative (HCIR) credentialing requirements to gain and maintain entry into facilities and organizations that are in your assigned territory. You must also be in good standing and/or eligible to obtain these credentials. These HCIR credentialing requirements may include, but are not limited to, background checks, drug screens, proof of immunization/vaccination for various diseases, fingerprinting and, • Valid driver’s license: Ability to pass a pre-employment drug screening test and meet safe driving requirements. Driving a personal auto or company car or truck, or a powered piece of material handling equipment Additional Information Applicable only to applicants applying to a position in any location with pay disclosure requirements under state or local law: The compensation range described below is the range of possible base pay compensation that the Company believes in good faith it will pay for this role at the time of this posting based on the job grade for this position. Individual compensation paid within this range will depend on many factors including geographic location, and we may ultimately pay more or less than the posted range. This range may be modified in the future. We offer a comprehensive package of benefits including paid time off (vacation, holidays, sick), medical/dental/vision insurance and 401(k) to eligible employees. This job is eligible to participate in our short-term incentive programs. Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, incentive, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole and absolute discretion unless and until paid and may be modified at the Company’s sole and absolute discretion, consistent with applicable law. AbbVie is an equal opportunity employer and is committed to operating with integrity, driving innovation, transforming lives and serving our community. Equal Opportunity Employer/Veterans/Disabled. US & Puerto Rico only - to learn more, visit https://www.abbvie.com/join-us/equal-employment-opportunity-employer.html US & Puerto Rico applicants seeking a reasonable accommodation, click here to learn more: https://www.abbvie.com/join-us/reasonable-accommodations.html

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