Appeals Clinical Consultant

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

Under the direction of the Director, Appeals & Grievances, the Clinical Consultant – Appeals & Grievances (A&G) will perform a variety of roles that focus on clinical support of department staff as well as develop effective working relationships with internal partner departments and vendors utilized by the Appeals & Grievances Department. The Clinical Consultant – A&G will be the liaison for all clinical issues involved in the Appeals & Grievances work. This role will assist with support and providing responses to escalate member and provider issues.

The position requires a highly motivated individual with an understanding of Appeals & Grievances processes, particularly in the managed care environment with a focus Commercial plans and Medicaid. Critical to the success of this role is the ability to demonstrate strength working independently as well as collaboratively within the team environment.

Job Description

• Serves as key clinical resource for various aspects of Appeal & Grievances work
• Provide support to Analyst team in developing knowledge and understanding of medical terminology and provider plan of care relative to appeal.
• Utilize clinical knowledge to analyze, assess, and consult with Analyst to determine the need for various aspects of physician review
• Identifies complex members and collaborate with Analyst to refer members to case management or disease management program based on member specific diagnoses, circumstances or psycho social needs, and product / LOB program requirements, with the goal of improving individual member satisfaction
• Assess drivers of appeals and grievance trends and work with A&G leadership in developing messaging to internal stakeholders (SLT, Product Team, Stars Team etc.)
• Consults with Analyst and MD reviewers on complex appeals and grievances
• Assist Analyst with case preparation and participate as a voting member in cross-functional Appeals Committees providing clinical input within scope of practice for appeal decisions.
• Assist department trainer with new hire training as it relates to clinical aspects of A&G work
• Other duties and projects as assigned.

Salary Range

$ -$

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