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Who We ArePoint32Health 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. To learn more about who we are at Point32Health, click here (https://youtu.be/S5IHgoecJQ) .Job SummaryUnder the direction of the Precertification Manager the Program Coordinator is responsible for the daily management of non-clinical reviews supporting the clinical, business and program related work of the department. The Program Coordinator 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.Key Responsibilities/Duties – what you will be doingPerforms initial pre-review validation and triage of requests received via the authorization system:
Reviews medical information received to ensure multiple requests are separated and all documentation is assigned to the correct member.
Verifies member eligibility and benefit availability using all applicable systems (TahpMaster ,CMT, HRP, DMS).
Identifies special coverage and confidential communication requirements and follows correct process to handle these issue
Performs basic coverage reviews:
Following coverage guidelines on certain request types (i.e. physical therapy or initial homecare) while checking benefit limits and restrictions. Responsible for managing complete process including sending authorization information and/or letters to the correct providers and members.
Voids events when the member is ineligible and notifies the provider via fax.Under the direction of a Precertification reviewer, notifies provider office staff via phone or fax when Commercial product requests do not require review.
Participates in department projects and special assignments for cross-coverage purposes to meet strict daily processing deadlines.
Assists with the documentation of workflows and procedures and trains co-workers as needed.Able to cross-train to handle requests for other teams within the Precertification department
Qualifications – what you need to perform the jobEDUCATION: (Minimum education & certifications required)
Associates Degree or equivalent relevant work experience is required; Bachelor’s Degree is preferred.
EXPERIENCE:
Two plus years of experience in a business environment required, managed care/health industry environment experience preferred.
SKILL REQUIREMENTS: (Include interpersonal skills)
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.
Strong organizational and problem solving 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.)
Has the ability to work as part of a team in an end to end process so that their work product is of a quality and quantity that ensures overall compliance with regulatory requirements.
Compensation & Total Rewards OverviewAs 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/Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health EquityPoint32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's 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.At Point32Health, we strive to be a different kind of nonprofit health and well-being company, with a broad range of health plans, and innovative tools that make navigating health and well-being easier, guiding our members at every step of their health care journey to better health outcomes. We are committed to providing high-quality and affordable health care, improving the health and wellness of our members, and creating healthier communities across the country. The Point32Health name is inspired by the 32 points on a compass. It speaks to the critical role we play in guiding and empowering the people we serve to achieve healthier lives. Our employees are hard-working, innovative, and collaborative. They look for opportunities to grow and make a difference, and they help make us strive to be one of the Top Places to work in New England.
