Appeals Clinical Consultant

Point32Health • Remote Worker Home Office (MA), MA

6d

About The Position

Under the direction of the Director, Appeals & Grievances, the Clinical Consultant – Appeals & Grievances provides clinical support to department staff and develops effective working relationships with internal partner departments and vendors. The role serves as the liaison for clinical issues involved in Appeals & Grievances work and supports responses to escalated member and provider issues.

The position requires an understanding of Appeals & Grievances processes, particularly in a managed care environment, with a focus on Commercial plans and Medicaid. Success requires the ability to work independently and collaboratively within a team.

Requirements

• Understanding of Appeals & Grievances processes, particularly in a managed care environment focused on Commercial plans and Medicaid.
• Ability to work independently and collaboratively within a team.

Responsibilities

• Serve as a key clinical resource for various aspects of Appeals & Grievances work.
• Support the Analyst team in developing knowledge of medical terminology and provider plans of care relevant to appeals.
• Use clinical knowledge to analyze and assess cases and consult with Analysts about the need for physician review.
• Identify complex members and collaborate with Analysts on referrals to case management or disease management programs based on diagnoses, circumstances, psychosocial needs, and product or line-of-business requirements, with the goal of improving member satisfaction.
• Assess drivers of appeals and grievance trends and work with A&G leadership to develop messaging for internal stakeholders, including the Senior Leadership Team, Product Team, and Stars Team.
• Consult with Analysts and physician reviewers on complex appeals and grievances.
• Assist Analysts with case preparation and participate as a voting member in cross-functional Appeals Committees, providing clinical input within scope of practice for appeal decisions.
• Assist the department trainer with new-hire training related to the clinical aspects of A&G work.
• Perform other duties and projects as assigned.

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
• Benefits supporting career development, individual and family health, and financial health
• Eligibility for variable pay

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed