Medical Director, Clinical Reviews

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. 

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

Job Summary

The Medical Director, Clinical reviews will primarily perform utilization management and provider payment reviews for all Point32Health products, as well as any partner entities at the direction of the Medical Director for Utilization Management. These functions will include prospective, concurrent, and retrospective utilization reviews including both member-facing initial reviews and appeals. They will work closely with staff from all partners of UM (Utilization Management), Medical Management Departments on these review activities. They will also work closely with other departments including Claims Operations, Actuarial, and Quality Management and assist with performing clinical reviews of provider claims payment disputes, perform retrospective claims audits of medical records, review of potential quality of care issues as well as credentialing of Providers and Facilities. Essential functions may occur simultaneously, therefore, the Medical Director, Clinical reviews, 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. The ability to learn and apply company policies consistently, seeking out guidance, when necessary, will be of utmost importance.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Utilization Management
  • Performs 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
  • Communicates with providers, provider groups, facilities, and others as necessary to obtain information and any resolve clinical issues and concerns
  • Supports the provider inquiry process for peer-to-peer discussions
  • Performs clinical review of expedited and standard appeals for all lines of business
  • Provides physician expertise and input for provider payment disputes
  • Participates in biannual inter-rater reliability exercises
• Quality and Credentialing
  • Perform Quality of care reviews for Occurrences and Grievances
  • Assist with credentialing reviews for providers and facilities
• Administrative
  • Participate in staff meetings and relevant committees as requested by supervisor
  • May 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.

Qualifications – what you need to perform the job

Certification and Licensure

• Current unrestricted license as a medical or osteopathic doctor.

Education

• Required (minimum): Board-Certified MD or DO in one of the American Board of Medical Specialties. For the Behavioral Health Specialty, the candidate will be an American Board of Psychiatry and Neurology Board-Certified MD or DO in Psychiatry.
• Preferred:

Experience

• Required (minimum): Five years of clinical experience
• Preferred: Utilization management, quality and / or management experience, either at another health plan or at a local provider unit, medical group, or health care facility.

Skill Requirements

• Perform 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 m