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 Clinical Reviewer is a licensed Registered Nurse that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for making the determination of medical necessity and, therefore, benefit coverage for Commercial members.
The Clinical Reviewer ensures consistent and timely disposition of coverage decisions as required by product specific compliance and regulatory time frames. The Clinical Reviewer functions as a member of the Precert / Outpatient UM team and works under the general direction of the Precertification Team Manager or department Manager. The Clinical Reviewer is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer will be expected to demonstrate sound clinical and health plan business knowledge in their decision-making processes, on behalf of the health plan.

Key Responsibilities/Duties – what you will be doing

Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames.
Collaborates with Medical Directors when determination to deny a request is indicated, advising the Medical Directors on standard business processes, ensuring those processes are followed or variances to the process are escalated, if needed, and agreed to and well documented.
Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter.
Communicates frequently through the day with physicians, practices, facilities and/or allied health providers.
Communicates frequently through the day with external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases.
Orients new staff to role as needed.
Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
Facilitates communication between Precertification and other internal departments by acting as a liaison or committee member on the development or implementation of new programs.
Provides input to the Medical Policy Department regarding the development of Medical Necessity Guidelines and adding input to purchased criteria through participation in the IMPAC.
Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes.
Assists in the screening of appeal cases to provide clinical input as needed or requested.
Models professionalism and leadership in all capacities of the position to all audiences.

Qualifications – what you need to perform the job

EDUCATION:
- Bachelor’s degree in Nursing preferred
- Registered Nurse with a current and unrestricted Massachusetts license required
EXPERIENCE:
- Minimum of five years clinical experience in utilization management, case management or quality assurance preferred
- Previous experience in a managed care setting desirable
SKILL REQUIREMENTS:
- Requires an individual with highly developed critical thinking skills and the ability to investigate, evaluate and problem solve using sound clinical judgment and business knowledge.
- Requires the ability to work in an extremely complex and fast-paced production environment.
- Demonstrates skill in responding to inquiries from providers and/or members
- Must exhibit initiative and creativity in planning of work and be able to resolve cases correctly, effectively, expeditiously and within tight timeframes.
- Good organizational skills and a customer centered focus required.
- Individual must be able to use multiple software applications simultaneously.
- Excellent oral and written communication skills required.

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