Appeals Clinical Consultant

🔥 12 hours ago

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 10%

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Point32Health

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🛡️ Insurance

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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.

📋 Description

• Serve as a key clinical resource for various aspects of Appeals & Grievances work • Support Analyst teams in developing knowledge of medical terminology and provider plans of care • Analyze and assess cases and consult with Analysts regarding physician review • Identify complex members and collaborate with Analysts to refer them to case management or disease management programs • Assess appeal and grievance trends and help leadership develop messaging for internal stakeholders • Consult with Analysts and MD reviewers on complex appeals and grievances • Assist Analysts with case preparation and participate as a voting member in cross-functional Appeals Committees • Provide clinical input within scope of practice for appeal decisions • Assist with new-hire training on clinical aspects of Appeals & Grievances work • Perform other duties and projects as assigned

🎯 Requirements

• Understanding of Appeals & Grievances processes, particularly in the managed care environment • Focus on Commercial plans and Medicaid • Clinical knowledge and ability to understand medical terminology and provider plans of care • Ability to analyze and assess appeals and grievances • Ability to work independently and collaboratively within a team environment • Ability to identify complex members and refer them to case management or disease management programs • Ability to assess appeal and grievance trends • Ability to provide clinical input within scope of practice • Credentials and experience appropriate to the role, as evaluated by the employer

🏖️ 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 • Variable pay eligibility

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