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 validate data integrity and the accuracy of performance reporting drawn from Jiva, the BHPS data warehouse, and related platforms.
• Identify performance variation across clients and product lines, and lead targeted improvement initiatives to close gaps.
• Use data analytics and quality metrics to monitor program performance, identify opportunities, and implement evidence-based best practices.

Enterprise & Market Alignment

• Serve as the primary internal liaison between BHPS Clinical Operations and market-facing teams (Sales, Account Management, Network) on matters related to case management and outcomes performance.
• Translate clinical strategies, performance goals, and care models into standardized, client-level execution.
• Ensure alignment and consistency of case management practices across BHPS clients while accommodating appropriate plan-design, network, and regulatory variation.
• Standardize workflows, role expectations, and best practices across clinical teams while preserving flexibility where clinically or contractually warranted.
• Serve as the clinical resource lead for Humana

Client & Stakeholder Partnership

• Prepare and present clinical performance, program data, and outcomes to BHPS clients during monthly, quarterly, and annual business reviews.
• Interface with Network and Sales leaders, including those supporting BHPS and proprietary network products, to promote and implement case management and population health programs and to support client-facing calls and program performance reviews.
• Create and interpret reporting needs for both client and BHPS leadership teams to ensure department obligations and contractual KPIs are met.
• Collaborate with Medical Directors, nursing leadership, social work, pharmacy, population health, utilization management, and operational executives to support integrated care delivery.
• Serve as a subject matter expert for case management strategy during new client implementations, RFPs, growth opportunities, and program redesign initiatives.

Leadership & Talent Development

• Recruit, train, mentor, and develop Directors, Managers, and senior staff within case management and care coordination.
• Promote a culture of accountability, collaboration, clinical excellence, and continuous improvement across the BHPS Medical Management organization.
• Support workforce planning, role optimization, and leadership succession across the case management team.
• Foster staff development, engagement, and professional growth, including support for clinical certifications and ongoing education.

Strategic Initiatives & Change Management

• Lead or support BHPS enterprise initiatives related to value-based care readiness, care redesign, and population health strategy.
• Drive change management efforts to ensure consistent adoption of new models, tools (including Jiva enhancements), and performance expectations across teams.
• Provide executive-level insight and recommendations to senior leadership on case management performance, risks, and opportunities.

Essential Qualifications

Education

• Bachelor's degree in Nursing, Social Work, or a related clinical field required.
• Master's degree in Nursing, Social Work, Healthcare Administration, Public Health, Nursing Informatics, or Business Administration strongly preferred.

Licensure & Certification

• Active, unrestricted clinical license required (RN, LCSW, LMHC, or equivalent).
• Certified Case Manager (CCM), ACM, or equivalent case management certification required.
• Additional clinical certifications (e.g., Certified Diabetes Educator, Pediatric Nursing, Gerontological Nursing) a plus.

Experience

• 8-10+ years of progressive healthcare leadership experience, including substantial experience in case management, utilization management, or care coordination.
• Demonstrated success leading case management and outcomes/performance improvement across multiple clients, product lines, or populations.
• Proven experience leading leaders (Directors and Managers) required.
• Strong working knowledge of case management models, population health, managed care, the TPA business model, and healthcare regulations.
• Experience with URAC and/or NCQA accreditation and audit preparation required.
• Experience supporting commercial self-insured / ERISA clients and value-based care arrangements strongly preferred.
• Hands-on experience with ZeOmega Jiva strongly preferred; experience with Milliman Care Guidelines (MCG), InterQual, or Healthwise preferred.

Key Competencies

• Enterprise and systems thinking within a TPA / managed care environment
• Strong leadership, communication, and stakeholder engagement skills
• Clinical outcomes and performance analytics; data-driven decision-making
• Operational and financial acumen
• Change leadership and execution
• Program design, quality improvement, and accreditation readiness
• Strong executive communication and client-facing presentation skills
• Ability to lead cross-functional teams and manage complex, concurrent initiatives
• Proficiency with Microsoft Office (Word, Excel, PowerPoint) and comfort working in clinical platforms (Jiva preferred) and database environments