Point32Health

Research Scientist

• Support data collection and management, data project timelines, technical infrastructure, and other data tasks for research cohort studies
• Assist in developing and coordinating data collection tools, including surveys and data collection forms
• Maintain project databases such as REDCap and Ripple or similar systems
• Support database creation, data problem identification and resolution, and results reporting
• Participate in data review, cleaning, and organization
• Develop programs supporting database creation, data problem identification and resolution, and results reporting
• Collaborate with internal staff and external study partners
• Attend and actively participate in staff, data/operations, and co-investigator meetings
• Provide support to internal and external data and project collaborators
• Perform day-to-day general tasks in support of research studies
• Contribute to maintenance of software applications and relevant data and technical documentation
• Perform other duties and projects as assigned

Senior Research Assistant

Manager

• Lead analytic support for contract negotiations, strategic initiatives, and regulatory requests
• Manage analysts in designing and executing complex analyses measuring the financial impact of provider contracts and payment changes
• Maintain knowledge of provider contractual arrangements, value-based reimbursement mechanisms, and cost and utilization drivers
• Submit regulatory requests
• Coordinate and oversee annual provider-network re-contracting for commercial business
• Collaborate with Network Contracting, Provider Analytics, Accounting, Trends, and Reserving on provider risk deals
• Identify opportunities to improve Point32Health’s financial position through enhanced payment arrangements
• Manage development and enhancement of department tools
• Coordinate quarterly provider performance assessment reviews
• Participate in external provider meetings with Network Contracting staff
• Manage network service costing to support Actuarial product pricing
• Recruit, train, develop, and evaluate staff
• Manage team workload and timelines
• Support Sales RFPs as appropriate
• Perform other duties and projects as needed

Senior Manager, Network Performance

• Perform telephonic member outreach and face-to-face encounters to facilitate program enrollment
• Conduct departmental assessments and evaluate members holistically to identify needs, health goals, and barriers to wellness
• Develop, implement, and revise member-specific plans of care and care manager interventions
• Complete documentation according to departmental policy and regulatory standards
• Provide targeted health education and proactive condition-management strategies
• Communicate with providers and vendors involved in member care
• Coordinate safe transitions to the next level of care, including post-discharge instructions, services, and follow-up
• Implement strategies to prevent readmission
• Collaborate with interdisciplinary care teams to improve member outcomes
• Attend and present high-risk members at interdisciplinary rounds
• Maintain professional growth through self-directed learning

Care Manager, Nursing – Mandarin/Cantonese Speaking, Community Experience

Data Analyst

• Complete complex business system and data analytic assignments supporting departmental objectives
• Collaborate with internal business and external vendor constituents on business solutions
• Create technology roadmaps with business leadership across multiple departments
• Document requirements, business rules, data standards, and technical specifications
• Develop design recommendations compliant with architectural standards and federal and state privacy and security requirements
• Facilitate design reviews with governing committees
• Plan, develop, and implement complex solution designs
• Develop application or extract program code, production reports, and analytic finding reports
• Lead junior analysts on complex solution components
• Lead QA and user acceptance testing planning and participate in business requester testing
• Develop and train IT and business personnel on testing strategies, plans, and scripts
• Execute test procedures and report results to project stakeholders
• Maintain core reference domain content using master data management tools
• Monitor dataset quality thresholds and manage data remediation projects
• Monitor production processes and resolve issues through root-cause analysis and modifications
• Perform other duties and projects as assigned

Senior Business Data Analyst

Medical Reviewer

• Provide utilization management activities for members in inpatient settings
• Apply industry-standard and plan-proprietary criteria to determine appropriateness of inpatient and post-acute settings on initial and concurrent reviews
• Determine reimbursement methodology and schedule concurrent reviews
• Review inpatient admissions and continued stays for length of stay, medical necessity, and discharge planning
• Identify and determine medical necessity for out-of-network requests
• Perform discharge planning for acute and post-acute admissions
• Identify complex members and refer them to case management or disease management programs
• Redirect members and providers to in-network or preferred providers
• Identify potential High Risk High Needs members and present them at Consultive Rounds
• Conduct preauthorization of transplant requests as required
• Complete case documentation, daily tasks, UM event management, and same-day case data entry
• Mentor new and existing staff on process and system changes
• Facilitate UM/CM Consultive Rounds
• Serve as a subject matter expert supporting Inpatient Management initiatives and systems including MedHOK, Case Trakker, and Jiva
• Assist the Team Manager with day-to-day team activities and assignments
• Develop collaborative relationships with partner departments and key customers
• Prepare cases for and participate in weekly UM/CM Consultive Rounds
• Participate in committees or serve as team liaison as needed
• Maintain professional growth and development
• Perform additional related duties as assigned

Clinical Reviewer, Inpatient RN

Clinician

• Perform clinical decision-making and utilization management for clinically complex services and coverage requests
• Determine medical necessity and benefit coverage using applicable coverage documents, clinical guidelines and Medical Necessity Guidelines
• Ensure consistent and timely coverage decisions within product-specific compliance and regulatory timeframes
• Collaborate with Medical Directors on adverse determinations and document process variances
• Coach letter writers on appropriate medical necessity language for denial letters
• Communicate with physicians, practices, facilities, allied health providers and external customers regarding determinations and case status
• Orient new staff as needed
• Liaise between Precertification staff and providers on policy interpretation, access availability and quality assurance issues
• Facilitate communication between Precertification and internal departments on new program development and implementation
• Provide input to the Medical Policy Department on Medical Necessity Guidelines and purchased criteria through IMPAC medical systems
• Identify Utilization Management trends in precertification and outpatient UM processes
• Assist with clinical screening of appeal cases
• Model professionalism and leadership
• Perform other assigned projects and duties

Outpatient Clinician RN Reviewer

• Perform utilization management, medical necessity determinations and benefit determinations for clinically complex services and coverage requests
• Apply coverage documents, purchased clinical guidelines and Medical Necessity Guidelines consistently within product-specific timeframes
• Collaborate with Medical Directors on denial determinations and ensure standard business processes are followed and documented
• Coach letter writers on appropriate medical necessity language for denial letters
• Communicate with physicians, practices, facilities, allied health providers and external customers regarding determinations and case status
• Orient new staff as needed
• Interface between Precertification staff and providers regarding policy interpretation, access availability and quality assurance issues
• Facilitate communication between Precertification and internal departments as a liaison or committee member for new programs
• Provide input to the Medical Policy Department on Medical Necessity Guidelines and purchased criteria through IMPAC medical systems
• Identify Utilization Management trends in precertification and outpatient UM processes
• Assist in screening appeal cases and provide clinical input
• Model professionalism and leadership
• Perform other projects and duties as assigned

Outpatient Clinician, RN Reviewer

• Manage a clinically complex caseload of varied service requests
• Perform utilization management, medical necessity determinations and benefit determinations using coverage documents, clinical guidelines and Medical Necessity Guidelines
• Ensure consistent and timely coverage decisions within product-specific compliance and regulatory time frames
• Collaborate with Medical Directors on denial determinations and business processes
• Coach letter writers on appropriate medical necessity language for denial letters
• Communicate with physicians, practices, facilities, allied health providers and external customers regarding determinations and case status
• Orient new staff as needed
• Interface between Precertification staff and providers regarding policy interpretation, access availability and quality assurance issues
• Facilitate communication between Precertification and internal departments on new program development or implementation
• Provide input to the Medical Policy Department on Medical Necessity Guidelines and purchased criteria through IMPAC medical systems
• Identify Utilization Management trends in precertification and outpatient UM processes
• Assist with screening appeal cases and provide clinical input
• Model professionalism and leadership
• Complete other projects and duties as assigned

Intake Coordinator

• Receive incoming authorization requests from providers via fax, portal, and telephone
• Create events or transactions by lines of business for utilization management teams to review and decide requests
• Contact provider offices for additional clinical information
• Research member eligibility and primary care selection
• Document and maintain telephone calls, admissions, referrals, messages, forms, and logs
• Work with providers and members to resolve complex and urgent issues
• Involve appropriate personnel and departments across the organization
• Enter authorization requests for inpatient stays and outpatient requests into information systems
• Represent Medical Management in system user groups and other health data system organizations
• Attend organization-wide and department staff meetings
• Maintain professional growth through self-directed learning and professional, civic, and community organizations
• Perform other duties assigned by Intake and Outreach Coordination leadership