Appeals Clinical Consultant

Point32Health; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Point32Health is seeking a Clinical Consultant – Appeals & Grievances to provide clinical support to the Appeals & Grievances team and act as the liaison for clinical issues across internal partners and vendors. You will work independently and with cross-functional groups to address member and provider issues, applying medical terminology and review processes.

This role emphasizes collaboration with analysts, MD reviewers, and cross-functional committees to improve appeal outcomes within managed

Qualifications

• Must have clinical knowledge relevant to appeals and grievances.
• Understanding of managed care review processes and terminology.
• Experience collaborating with analysts and MD reviewers.

Responsibilities

• Serve as clinical resource for Appeal & Grievances work.
• Support Analyst team in medical terminology and care plans.
• Analyze and consult on physician review needs.
• Identify complex members and refer to case management as needed.
• Assess drivers of appeals trends and report to leadership.
• Consult MD reviewers on complex appeals and grievances.
• Assist with case preparation and participate in cross-functional committees.
• Assist trainer with new hire clinical onboarding.
• Perform other duties as assigned.

Skills

Clinical knowledge

Appeals & Grievances

Cross-functional collaboration

Independent worker

Education

MD or DO or equivalent

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 evolve 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 andbenefits remains in the Company’s sole discretion and maybe 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.