Who We Are
Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.
Job Summary
The Medical Director, Clinical reviews will primarily perform utilization management and provider payment reviews for all Point32Health products, as well as any partner entities at the direction of the Medical Director for Utilization Management. These functions will include prospective, concurrent, and retrospective utilization reviews including both member-facing initial reviews and appeals. They will work closely with staff from all partners of UM (Utilization Management), Medical Management Departments on these review activities. They will also work closely with other departments including Claims Operations, Actuarial, and Quality Management and assist with performing clinical reviews of provider claims payment disputes, perform retrospective claims audits of medical records, review of potential quality of care issues as well as credentialing of Providers and Facilities.Essential functions may occur simultaneously, therefore, the Medical Director, Clinical reviews, must be able to appropriately handle each essential function, prioritize them and seek assistance when necessary. The expectation is for these functions to be performed on a consistent and regular basis, using good judgment. The ability to learn and apply company policies consistently, seeking out guidance, when necessary, will be of utmost importance.
Key Responsibilities/Duties – what you will be doing
Key Responsibilities/Duties – what you will be doing (top five):
- Utilization Management
- Performs clinical review of prospective, concurrent, and retrospective coverage requests for in-patient and out-patient services requiring prior authorization and medical necessity review for all lines of business
- Communicates with providers, provider groups, facilities, and others as necessary to obtain information and any resolve clinical issues and concerns
- Supports the provider inquiry process for peer-to-peer discussions
- Performs clinical review of expedited and standard appeals for all lines of business
- Provides physician expertise and input for provider payment disputes
- Participates in biannual inter-rater reliability exercises
- Quality and Credentialing
- Perform Quality of care reviews for Occurrences and Grievances
- Assist with credentialing reviews for providers and facilities
- Administrative
- Participate in staff meetings and relevant committees as requested by supervisor
- May assist with oversight of delegated entities at the request of supervisor
- Assist with creating and developing departmental policies as needed
- Assist with regulatory requirements including external and internal audits and monitoring
- Other projects and duties as assigned.
Qualifications – what you need to perform the job
Qualifications – what you need to perform the job
Certification and Licensure
- Current unrestricted license as a medical or osteopathic doctor.
Education
- Required (minimum): Board-Certified MD or DO in one of the American Board of Medical Specialties. For the Behavioral Health Specialty, the candidate will be an American Board of Psychiatry and Neurology Board-Certified MD or DO in Psychiatry.
- Preferred:
Experience
- Required (minimum): Five years of clinical experience
- Preferred: Utilization management, quality and / or management experience, either at another health plan or at a local provider unit, medical group, or health care facility.
Skill Requirements
- Perform utilization management activities in accordance with accreditation standards and regulatory guidelines described in legacy Tufts Health Plan or Harvard Pilgrim Health Care UM Policy and Procedure Manual
- Render medical necessity coverage determinations in accordance with legacy Tufts Health Plan or Harvard Pilgrim Health Care Medical Necessity Guidelines and the member’s EOC (Evidence of Coverage) / benefit document
- Render provider appeal decisions following legacy Tufts Health Plan or Harvard Pilgrim Health Care claims payment policies
- Have an understanding of the principles of utilization management and quality assurance.
- Have the skills to communicate with and educate Point32Health peers as well as Tufts Health Plan or Harvard Pilgrim Health Care participating physicians and other providers in a collegial manner.
- Be an effective team player, with excellent interpersonal, cross-departmental collaboration and leadership skills.
Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):
- 8-hour full-day or 4-hour half-day blocks of work based on schedule and FTE.
- Point32Health is a fast-paced professional environment requiring a high level of initiative and robust decision-making skills.
- The Physician Reviewer will be given appropriate training in all the Healthcare services applications used at legacy Tufts Health Plan or Harvard Pilgrim Health Care.
- Must be able to work under normal office conditions and/or work from home as required.
- Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
- May be required to work additional hours beyond standard work schedule.
The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.
Compensation & Total Rewards Overview
As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.
Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:
Medical, dental and vision coverage
Retirement plans
Paid time off
Employer-paid life and disability insurance with additional buy-up coverage options
Tuition program
Well-being benefits
Full suite of benefits to support career development, individual & family health, and financial health
For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/
Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity
Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org
