Job Summary

The Medical Director, Clinical reviews (Behavioral Health) will primarily perform Behavioral Health utilization management reviews and provider payment reviews for all Point32Health products, as well as any partner entities at the direction of Medical Director for Utilization Management. These functions will include prospective, concurrent, and retrospective utilization reviews including both member facing initial reviews and appeals. They will work closely with staff from all partner UM, Medical Management Departments on these  review activities. They will also work closely with other departments including Claims Operations, Actuarial, and Quality Management and assist with performing clinical reviews of provider claims payment disputes, perform retrospective claims audits of medical records, review of potential quality of care issues as well as credentialing of Providers and Facilities.

Essential functions may occur simultaneously, therefore, the Medical Director, Clinical reviews (Behavioral Health) must be able to appropriately handle each essential function, prioritize them and seek assistance when necessary.  The expectation is for these functions to be performed on a consistent and regular basis, using good judgment. Ability to learn and apply company policies consistently, seeking out guidance, when necessary, will be of utmost importance.

Key Responsibilities/Duties – what you will be doing

Utilization Management

• Performs clinical review of prospective, concurrent, and retrospective coverage requests for in-patient and out-patient services requiring prior authorization and medical necessity review for all lines of business
• Communicates May be required to communicatewith providers, provider groups, facilities, and others as necessary to obtain information and any resolve clinical issues and concerns
• Supports the provider inquiry line for peer-to-peer discussions
• Performs clinical review of expedited and standard appeals for all lines of business
• Provides physician expertise and input for provider payment disputes
• Participates in biannual inter-rater reliability exercises

75%

Quality and Credentialing

• Perform Quality of care reviews for Occurrences and Grievances
• Assist with credentialing reviews for providers and facilities

25%

Qualifications – what you need to perform the job

EDUCATION and EXPERIENCE: (Minimum educational qualifications)

• Candidate will be a American Board of Psychiatry and Neurology Board-Certified MD or DO in Psychiatry.
• Minimum of five years of clinical experience is required.
• Utilization management, quality and / or management experience, either at another health plan or at a local provider unit, medical group, or health care facility is preferred.

They are required to have a current unrestricted license as a medical or osteopathic doctor in Massachusetts.

SKILL REQUIREMENTS: (Includes interpersonal skills)

• Performs utilization management activities in accordance with accreditation standards and regulatory guidelines described in legacy Tufts Health Plan or Harvard Pilgrim Health Care UM Policy and Procedure Manual.
• Render medical necessity coverage determinations in accordance with legacy Tufts Health Plan or Harvard Pilgrim Health Care Medical Necessity Guidelines and the member’s EOC / benefit document.
• Render/provide appeal decisions following legacy Tufts Health Plan or Harvard Pilgrim Health Care claims payment policies
• Have an understanding of principles of utilization management and quality assurance.
• Have the skills to communicate with and educate Point32Health peers as well as Tufts Health Plan or Harvard Pilgrim Health Care participating physicians in a collegial manner.
• Be an effective team player, with excellent interpersonal, cross-departmental and leadership skills.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)

Point32Health is a fast-paced professional environment requiring a high level of initiative and robust decision-making skills.  Effective use of a company issued personal computer is important.  The Medical Director, Clinical reviews (Behavioral Health) will be given appropriate training in all the Healthcare services applications used at legacy Tufts Health Plan or Harvard Pilgrim Health Care.

We encourage a hybrid model for the first 90 days of employment with 1 to 3 days on-site per week. Remote work may be an option after first 90 days of employment and after approval of the same from the Supervisor.

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.

https://tuftshealthplan.wd5.myworkdayjobs.com/en-us/THP/details/Physician-Reviewer_R5365