Medical Director – Clinical Reviews

13 hours ago

🍂 Massachusetts – Remote

Although this job is listed in Massachusetts, this company may be open to hiring remote in other states.

💵 $229.7k - $344.5k / year

⏱ Part Time

🔴 Lead

👨‍⚕️ Medical Director

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Point32Health

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Healthcare Insurance • Non-profit • Wellness

Point32Health is a leading nonprofit health and well-being organization that provides health coverage and services for individuals at all life stages. Through its family of companies, including Harvard Pilgrim Health Care and Tufts Health Plan, Point32Health offers a variety of health plans, programs, and services encompassing medical, pharmacy, wellness, and behavioral health. Point32Health is committed to health equity and has been recognized for its inclusive practices, earning distinctions in areas such as health equity, disability inclusion, and LGBTQ+ workplace inclusion. With a focus on innovative solutions and high-quality coverage, Point32Health strives to create a better healthcare experience for its members and communities.

1001 - 5000 employees

⚕️ Healthcare Insurance

🤝 Non-profit

🧘 Wellness

📋 Description

• Perform clinical review of prospective, concurrent, and retrospective coverage requests for in-patient and out-patient services requiring prior authorization and medical necessity review for all lines of business • Communicate with providers, provider groups, facilities, and others as necessary to obtain information and resolve clinical issues and concerns • Support the provider inquiry process for peer-to-peer discussions • Perform clinical review of expedited and standard appeals for all lines of business • Provide physician expertise and input for provider payment disputes • Participate in biannual inter-rater reliability exercises • Perform Quality of care reviews for Occurrences and Grievances • Assist with credentialing reviews for providers and facilities • Participate in staff meetings and relevant committees as requested by supervisor • Assist with oversight of delegated entities at the request of supervisor • Assist with creating and developing departmental policies as needed • Assist with regulatory requirements including external and internal audits and monitoring • Other projects and duties as assigned.

🎯 Requirements

• Current unrestricted license as a medical or osteopathic doctor. • Board-Certified MD or DO in one of the American Board of Medical Specialties. • For the Behavioral Health Specialty, American Board of Psychiatry and Neurology Board-Certified MD or DO in Psychiatry. • Five years of clinical experience. • Utilization management, quality and / or management experience, at another health plan or at a local provider unit, medical group, or health care facility. • Skills to communicate with and educate Point32Health peers as well as Tufts Health Plan or Harvard Pilgrim Health Care participating physicians and other providers in a collegial manner. • An understanding of the principles of utilization management and quality assurance.

🏖️ Benefits

• 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