Clinical Consultant, Appeals & Grievances

Point32Health hiring for Clinical Consultant, Appeals & Grievances jobs in Chelsea, MA, US

Under the direction of the Director, Appeals & Grievances, the Clinical Consultant – Appeals & Grievances (A&G) will perform a variety of roles that focus on clinical support of department staff as well as develop effective working relationships with internal partner departments and vendors utilized by the Appeals & Grievances Department. The Clinical Consultant – A&G will be the liaison for all clinical issues involved in the Appeals & Grievances work. This role will assist with support and providing responses to escalate member and provider issues.

The position requires a highly motivated individual with an understanding of Appeals & Grievances processes, particularly in the managed care environment with a focus Medicare and Medicaid. Critical to the success of this role is the ability to demonstrate strength working independently as well as collaboratively within the team environment.

Key Responsibilities/Duties - What You Will Be Doing

• Serves as key clinical resource for various aspects of Appeal & Grievances work
• Provide support to Analyst team in developing knowledge and understanding of medical terminology and provider plan of care relative to appeal.
• Utilize clinical knowledge to analyze, assess, and consult with Analyst to determine the need for various aspects of physician review
• Identifies complex members and collaborate with Analyst to refer members to case management or disease management program based on member specific diagnoses, circumstances or psycho social needs, and product / LOB program requirements, with the goal of improving individual member satisfaction
• Assess drivers of appeals and grievance trends and work with A&G leadership in developing messaging to internal stakeholders (SLT, Product Team, Stars Team etc.)
• Consults with Analyst and MD reviewers on complex appeals and grievances
• Assist Analyst 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 department trainer with new hire training as it relates to clinical aspects of A&G work
• Other duties and projects as assigned.

Qualifications - What You Need To Perform The Job

Education, Certification and Licensure

• Registered Nurse with current state license
• BSN: Preferred

Experience (minimum years required):

• Minimum of five years of clinical nursing experience
• Managed Care experience preferred
• Appeals & Grievances or Utilization Management experience preferred

Skill Requirements

• Excellent verbal and written communication, active listening skills, and high-level presentation skills
• Ability to analyze and comprehend complex data
• Address multiple complex issues throughout the workday in a flexible professional manner.
• Requires initiative, sound judgment, and the ability to work under pressure in a constantly changing environment balancing multiple priorities and utilizing resources aggressively. Must be able to exercise appropriate judgment as necessary and raise issues to the appropriate level.
• Demonstrate strong clinical and critical thinking abilities.
• Must be self-directing, politically astute and have outstanding interpersonal, teaching, decision-making and presentation skills
• Strong PC skills utilizing Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R7526