Job Description:

We enjoy the important work we do every day on behalf of our members.

Job Summary

General Summary: Under the direction of the Precertification Team Manager the Review Specialist is responsible for the daily management of non-clinical reviews supporting the clinical, business and program related work of the department. The Specialist functions as a key member of the Utilization Management Team and department and is a representative of Tufts Health Plan values to both the internal and external customer through written and verbal communication. The 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

• Coordinates and performs the review process for special groups as designated through Tufts Health Plan such as Local 26, USFHP.

• 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 andassists 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 resolution

• 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

Requirements

EDUCATION: Bachelor's Degree or equivalent relevant work experience is strongly preferred .

EXPERIENCE: Three plus years of experience in a business environment required, managed care/health industry environment experience required. Evidence of strong writing skills. Call Center experience required.

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


• Has the ability to manage multiple priorities as well as possesses the initiative and judgment to operate within a politically sensitive framework.


• Exhibits initiative and is self-directed and self-motivated in work performance.


• Strong organizational, problem solving, and conflict resolution skills and the attention to detail necessary to act within a complex environment


• Excellent interpersonal skills. (Position requires daily contact, by telephone, with network providers and their office staff, hospital contacts and Tufts Health Plan internal departments


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WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS:

Fast paced office environment handling multiple demands.

Must be able to exercise appropriate judgement as necessary.

Work is done remotely and in an open cubicle office setting with other employees

Requires ability to sit for long periods of time performing data entry functions

May be required to work when the company is closed to meet business needs

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!

As of Nov. 1, 2021, full vaccination against COVID-19 is required to enter any Point32Health office or if, on behalf of Point32Health, you are meeting in-person with individuals outside of a Point32Health office. As of Dec. 8, 2021, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

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