UM Specialist

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

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.

Job Description

Key Responsibilities/Duties– what you will be doing:

• 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.

Qualifications – what you need to perform the job

Certification and Licensure

Education

• Required (minimum): Bachelor’s Degree or equivalent relevant work experience
• Preferred:

Experience

• Required (minimum): 3+ years of experience in a managed care/health industry environment experience
• Preferred:

Skill 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.

Working Conditions and Additional Requirements (include specific requirements, e.g., lifting, travel):

• 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.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$24.03 -$36.05

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization.  The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• 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

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all
All applicants are welcome and 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.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact [email protected]