Appeals Clinical Consultant

Point32Health Services; United States; On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Retirement plan

Paid time off

Life and disability insurance

Tuition program

Well-being benefits

Job summary

Point32Health is seeking a Clinical Consultant - Appeals & Grievances to support the department’s clinical operations and act as a liaison with internal teams and vendors. The role focuses on clinical guidance for appeals, collaboration with analysts, and independent work within a managed care environment covering Commercial and Medicaid programs.

Ideal candidates bring a strong clinical foundation, experience with grievances processes, and the ability to communicate complex medical concepts

Qualifications

• Clinical background in appeals/grievances and managed care.
• Ability to interpret medical terminology and plan of care.
• Experience interacting with analysts and cross-functional teams.

Responsibilities

• Serve as key clinical resource for Appeals & Grievances.
• Support analysts in medical terminology and provider plans.
• Analyze and advise on physician review needs.
• Identify complex cases and refer to case management as needed.
• Assess appeals drivers and assist leadership with messaging.
• Consult with MD reviewers on complex cases.
• Assist in case preparation and participate in committees.
• Contribute to new hire training on clinical aspects.
• Handle other duties as assigned.

Skills

Clinical knowledge

Communication skills

Independent work

Cross-functional collaboration

Job 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

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 elevate 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.