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

As a Medical Audit Claim Reviewer, you will play a crucial role in our organization by reviewing and auditing medical claims to ensure compliance with policies, procedures, and regulatory requirements. You will contribute to the accurate and ethical processing of claims, which is essential for the well-being of our members and the financial stability of our organization.

Key Responsibilities/Duties – what you will be doing

Review and audit medical claims to ensure accuracy, completeness, and compliance with company policies and relevant regulations.
Examine medical records, bills, and other relevant documentation to validate the appropriateness of the claims submitted.
Stay up to date with healthcare regulations and industry standards to ensure that all claims meet legal and ethical requirements.
Verify the medical necessity of procedures, services, and medications, and confirm that they align with the patient's diagnosis.
Accurately document findings and actions taken during claim reviews in our audit management system.
Collaborate with healthcare providers, insurance adjusters, and other stakeholders to request additional information, clarify discrepancies, and provide feedback on claim reviews.
Generate reports and summaries of audit findings to support quality improvement initiatives.
Participate in ongoing training and professional development to stay current with industry best practices and regulations

Other projects and duties as assigned.

Qualifications – what you need to perform the job

Education

Required (minimum): BSN (Bachelor's Science in Nursing)
Preferred: Master’s degree

Experience (minimum years required):

Required (minimum): 5-7 years of experience in medical claim auditing, healthcare compliance, or a related role.
Preferred: 8-10 years of related work experience

Skill Requirements

Knowledge of medical billing and coding, healthcare regulations, and industry standards.
Strong analytical and critical thinking skills.
Excellent attention to detail and the ability to work independently.
Effective communication and interpersonal skills.
Proficiency in using relevant software and tools for claim auditing.
Knowledge of health insurance processes and terminology is a plus.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

Must be able to work under normal office conditions and work from home as required.

Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
May be required to work additional hours beyond standard work schedule.

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.