Senior Director, Case Management & Outcomes Performance

About The Role Brighton Health Plan Solutions (BHPS) is a Third Party Administrator (TPA) serving 400,000+ commercial members across employer-sponsored self-insured plans and proprietary network products, including MagnaCare. The Senior Director, Case Management & Outcomes Performance is a senior clinical and operational leader responsible for the strategic direction, design, and performance of BHPS’s case management, disease management, and population health programs. This role ensures the delivery of high-quality, member-centered, cost-effective care while aligning case management strategy, clinical outcomes, and utilization excellence across BHPS’s book of business, client segments, and clinical operations. Reporting to the VP, Clinical Operations, the Senior Director acts as a key internal liaison between Clinical Operations and BHPS’s market-facing teams—partnering closely with clinical, operational, quality, finance, network, sales, and growth leaders to drive measurable improvements in outcomes, utilization, value-based performance, regulatory compliance, and client satisfaction. This role is critical to ensuring consistent, high-performing case management operations within the BHPS TPA model and to maintaining accreditation and regulatory readiness across URAC, NCQA, CMS, ERISA, MHPAEA, the No Surprises Act, and HIPAA confidentiality requirements—with particular attention to obligations owed to self-insured clients. Primary Responsibilities Case Management Program Leadership Provide strategic direction and oversight for all BHPS case management activities, including complex case management, transitions of care, behavioral health, disease management, and population health programs serving commercial self-insured and network-based populations Design, develop, implement, and continuously enhance new and existing case management, disease management, and population health programs aligned with client contractual requirements, regulatory expectations, accreditation standards, and BHPS organizational priorities Coordinate care management operations across the full client lifecycle—from RFP and implementation through onboarding, go-live, and ongoing oversight—while meeting regulatory timelines and client KPIs Establish quality standards and own department policies and procedures (including Single Case Agreement / LOA, transitions of care, and complex case management workflows) that guide organizational integrity and operational efficiency Serve as BHPS’s clinical subject matter expert and advisor to senior leadership on case management strategy, models, and best practices for the TPA environment Clinical Oversight & Care Coordination Ensure evidence-based, holistic, and member-centered care coordination for high-risk and complex BHPS members Ensure each case is managed appropriately within ZeOmega Jiva (BHPS’s system of record) to support the provision of optimal medical care that is clinically sound and cost-effective Identify and escalate cases with potential quality or utilization concerns; lead root-cause analysis and corrective action where indicated Promote consistent, defensible application of recognized clinical decision-support resources (e.g., MCG) across the team Collaborate with BHPS Medical Directors, network providers, behavioral health, pharmacy, and community-based resources to support integrated care delivery and ensure documentation and care planning meet professional, contractual, and regulatory standards Compliance & Accreditation Ensure full compliance with state, federal, and accreditation requirements including URAC, NCQA, CMS, ERISA, MHPAEA, the No Surprises Act, and HIPAA confidentiality requirements—with particular attention to obligations owed to BHPS self-insured clients Lead preparation for URAC and NCQA audits, surveys, and accreditation reviews—including documentation, file review, mock audits, and staff readiness Partner with BHPS Compliance, Legal, and Quality leaders to maintain ongoing departmental compliance and remediate any identified gaps Maintain current policies, procedures, and training programs that support compliance, clinical quality, and consistent execution across the case management program Outcomes & Performance Leadership Lead the development, monitoring, and improvement of performance metrics related to clinical outcomes, utilization, throughput, readmissions, denial prevention, length of stay, member satisfaction, and total cost of care Establish and monitor key performance indicators (KPIs) for the case management program and lead continuous quality improvement initiatives and corrective action plans Partner with BHPS Quality, Finance, Business Intelligence, and Clinical Operations teams to valid