Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.

Job Summary

The Behavioral Health Psychologist Reviewer will primarily perform utilization management and provider payment reviews for all Point32Health products, as well as any partner entities at the direction of Behavioral Health Medical Director Team Leader for Utilization Management (UM) and/or the Medical Director of UM. These functions will include prospective, concurrent, and retrospective utilization reviews including both member facing initial reviews and appeals. They will work closely with colleagues in UM and Medical Management, and with other departments as needed, including but not limited to Claims Operations, Actuarial, and Quality Management. They will assist with performing clinical reviews of provider claims payment disputes, perform retrospective claims audits of medical records, and review potential quality of care issues and credentialing related to their specialties.

Essential functions may occur simultaneously; therefore, the Behavioral Health Psychologist Reviewer 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. Ability to learn and apply company policies consistently and to seek guidance, when necessary, will be of utmost importance.

Key Responsibilities/Duties – what you will be doing

Utilization Management

Performs clinical review of prospective, concurrent, and retrospective coverage requests for Neuropsychological and Psychological Testing 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 line for peer-to-peer discussions.
Performs clinical review of expedited and standard appeals for all lines of business.
Provides psychologist expertise and input for provider payment disputes.
Participates in biannual inter-rater reliability exercises.

Qualifications – what you need to perform the job

EDUCATION and EXPERIENCE: (Minimum educational qualifications)

Candidate will be a Ph.D. or Psy.D. psychologist.
Minimum of five years of clinical experience is required.
Significant utilization management, quality and / or management experience, either at another health plan or at a local provider unit, medical group, or health care facility is preferred.
They are required to have a current unrestricted license as a psychologist in Massachusetts

SKILL REQUIREMENTS:

Performs 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 / benefit document.
Render/provide appeal decisions following legacy Tufts Health Plan or Harvard Pilgrim Health Care claims payment policies.
Have an understanding of 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 psychologists and other providers in a collegial manner.
Be an effective team player, with excellent interpersonal and cross-departmental collaboration skills.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel,

overtime)

Point32Health is a fast-paced professional environment requiring a high level of initiative and robust decision-making skills. Effective use of a company issued personal computer is important. The Behavioral Health Psychologist Reviewer will be given appropriate training in all the Healthcare services applications used at legacy Tufts Health Plan or Harvard Pilgrim Health Care.

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Point32Health is considered confidential. The employee will be exposed to and required to deal with highly confidential and sensitive material and must always adhere to corporate compliance policy and department guidelines/policies and all applicable laws and regulations.

Compensation & Total Rewards Overview

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/

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who 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