Senior Clinical Appeals Specialist

Point32Health, Inc.; Massachusetts; Presencial; USD 90.000 - 120.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical coverage

Retirement plans

Paid time off

Life and disability insurance

Tuition program

Well-being benefits

Career development support

Descripción de la vacante

Point32Health is seeking a Clinical Consultant – Appeals & Grievances to support the A&G department under the Director. The role focuses on clinical support of staff, acting as the clinical liaison for all appeals issues, and collaborating with vendors and internal partners.

You will assist with case preparation, participate in Appeals Committees, and help train new staff. A strong understanding of managed care processes for commercial and Medicaid plans is essential, with the ability to work

Responsabilidades

• 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.

Descripción del empleo

Point32Health is seeking a Clinical Consultant – Appeals & Grievances to support the A&G department under the Director. The role focuses on clinical support of staff, acting as the clinical liaison for all appeals issues, and collaborating with vendors and internal partners.

You will assist with case preparation, participate in Appeals Committees, and help train new staff. A strong understanding of managed care processes for commercial and Medicaid plans is essential, with the ability to work