UM Specialist

Point32Health • Canton, MA

5d • $24 - $36 • Remote

About The Position

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 Under the direction of the Precertification Team Manager, the UM Specialist is responsible for the daily management of non-clinical reviews supporting the clinical, business and program related work of the Utilization Management (UM) department. The Specialist functions as a key member of the Utilization Management Team and department and is a representative of Point32Health’s values to both the internal and external customer through written and verbal communication. The UM Specialist is responsible for coordination of coverage determinations for special handling of designated products or accounts, all medical necessity denial letters and monitoring of daily processes performed by the coordinator.

Requirements

• Excellent verbal and written communication skills.
• Demonstrate proficiency and accuracy in performing data entry tasks in multiple applications.
• Appropriately identify urgent situations and follow the established protocol.
• Ability to manage multiple priorities and possess the initiative and judgment to operate within a sensitive framework.
• Exhibits initiative and is self-directed and initiative-taking in work performance.
• Strong organizational, problem solving, and conflict resolution skills and the attention to detail necessary to act within a complex environment.
• Excellent people skills. (Position requires daily contact, by telephone, with network providers and their office staff, hospital contacts and Point32Health Plan internal departments.
• 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 the standard work schedule.
• Bachelor’s Degree or equivalent relevant work experience
• 3+ years of experience in a managed care/health industry environment experience

Nice To Haves

• Certification and Licensure

Responsibilities

• Writes and edits all denial letters for medical necessity.
• Participates in a structured training program for new staff.
• Assists in training of existing new employees as new procedures and systems are introduced.
• Conducts staff audits and assists with managing monitoring tools to ensure quality of work by coordinators.
• Assists partner departments to resolve claims discrepancies and resolve misdirected activity – exploring root causes and recommendations for re solution.
• Participates in advanced departmental operational and administrative processes such as requests for departmental information and follow up as requested.
• Participates in projects and special assignments for purposes of meeting timeliness and department compliance.
• Required to represent the department on committees as requested.
• Other projects and duties 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
• Full suite of benefits to support career development, individual & family health, and financial health

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level