Point32Health

Compensation

Full Description

Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health. 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. Job Description 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 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. Disclaimer 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. Salary Range $229,685.41 -$344,528.11 Compensation & Total Rewards Overview The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. 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/ We welcome all All applicants are welcome and 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 Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.