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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.

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🏢 careers

Jobs at this company:

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🔥 Senior Care Options Transition RN

Posted 15 days ago

📍 United States of America

🔍 Health Care

🔧 Requirements

Registered Nurse with current unrestricted license in state of residence
Experience in home care or case management preferred
Proficiency in second language desirable
Experience in specialty areas such as oncology, neurology, chronic condition/disease management a plus

💡 Responsibilities

Administer assessments, collaborate with the member/caregiver and providers to develop a plan of care, implement member-specific CM interventions, and evaluate plan of care and revise as needed.
Facilitate program enrollment utilizing key motivational interviewing skills
Provide targeted health education, proactive strategies for condition management, and communication with key providers and vendors actively involved in the member’s care
Perform both telephonic and face to face outreach to assess barriers to wellness, medical, behavioral, and psychosocial needs of the member.
Collaborate with member/caregiver and the facility care team to coordinate a safe transition to the next level of care, which includes but is not limited to ensure understanding post-hospital discharge instructions, facilitate needed services and follow-up, and implement strategies to prevent re-admission
Performs case documentation in applicable CM system according to department and regulatory standards
Collaborates and liaises with the interdisciplinary care team, to improve member outcomes (i.e., Utilization Management, Medical Director, pharmacy, community health workers, dementia care specialists, wellness, and BH CM)
Attend and present (as appropriate), high risk members at interdisciplinary rounds forum
Maintain professional growth and development through self-directed learning activities
Other duties and projects as assigned.

Communication SkillsCollaborationTime ManagementDocumentationInterpersonal skillsAdaptabilityProblem-solving skillsCritical thinkingEmpathyActive listeningClient relationship management

Posted 15 days ago

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🔥 RN Outpatient Reviewer, Precertification Operations

Posted about 2 months ago

📍 United States of America

🔍 Health and Wellbeing

🔧 Requirements

Bachelor’s degree in Nursing preferred
Registered Nurse with a current and unrestricted Massachusetts license required

💡 Responsibilities

Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations
Collaborates with Medical Directors when determination to deny a request is indicated
Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter.
Communicates frequently through the day with physicians, practices, facilities and/or allied health providers.
Communicates frequently through the day with external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases.
Orients new staff to role as needed.
Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines.
Facilitates communication between Precertification and other internal departments by acting as a liaison or committee member on the development or implementation of new programs.
Provides input to the Medical Policy Department regarding the development of Medical Necessity Guidelines and adding input to purchased criteria through participation in the IMPAC.
Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes.
Assists in the screening of appeal cases to provide clinical input as needed or requested.
Models professionalism and leadership in all capacities of the position to all audiences.

Communication SkillsAnalytical SkillsCollaboration

Posted about 2 months ago

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