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Program Operations Specialist

2 months ago

Canton, Massachusetts, United States Point32Health Full time
Job Overview

Under the supervision of the Precertification Manager, the Program Operations Specialist is tasked with the daily oversight of non-clinical evaluations that support the clinical, business, and programmatic functions of the department.

The Program Operations Specialist serves as a vital member of the Utilization Management Team and embodies the values of Point32Health in all interactions with both internal and external stakeholders through effective written and verbal communication.

Key Responsibilities

  • Conducts initial pre-review validation and triage of requests received through the authorization system:
  • Reviews medical documentation to ensure that multiple requests are properly categorized and that all paperwork is linked to the correct member.
  • Confirms member eligibility and benefit availability utilizing all relevant systems.
  • Identifies special coverage needs and confidential communication protocols, ensuring adherence to established processes.

Executes basic coverage assessments:
  • Follows coverage guidelines for specific request types while verifying benefit limits and restrictions.
  • Manages the complete process, including the distribution of authorization information and letters to the appropriate providers and members.
  • Annuls requests when the member is deemed ineligible and communicates this to the provider.

Under the guidance of a Precertification reviewer, informs provider office staff when Commercial product requests do not necessitate further review.

Engages in departmental projects and special assignments to ensure compliance with strict daily processing timelines.

Assists in documenting workflows and procedures and provides training to colleagues as required. Capable of cross-training to manage requests for other teams within the Precertification department.

Qualifications

EDUCATION:

Associate's Degree or equivalent relevant work experience is mandatory; a Bachelor's Degree is preferred.


EXPERIENCE:

A minimum of two years of experience in a business setting is required, with a preference for experience in managed care or the health industry.


SKILL REQUIREMENTS:

Excellent verbal and written communication abilities.

Proficient and accurate in data entry across multiple applications.

Ability to recognize urgent situations and adhere to established protocols.

Demonstrated capacity to manage multiple priorities while exercising initiative and judgment within a politically sensitive environment.

Strong organizational and problem-solving skills, along with meticulous attention to detail necessary for navigating a complex environment.

Exceptional interpersonal skills, with daily interactions via telephone with network providers, their office staff, hospital contacts, and internal departments.

Ability to collaborate effectively as part of a team to ensure that work output meets quality and compliance standards.

Commitment to Diversity, Equity & Inclusion

Point32Health is dedicated to integrating diversity, equity, and inclusion into all aspects of our operations—from product design to workforce development.

Our DEI strategy is closely aligned with our core values and will adapt as the nature of work evolves.

We encourage all applicants and qualified individuals to apply, ensuring equal consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

About Us

Point32Health is a prominent health and wellness organization committed to delivering a personalized healthcare experience to all members of our communities.

We build upon the quality, nonprofit legacy of our founding organizations, leveraging our expertise to assist individuals in achieving their health and wellness goals through a comprehensive range of health plans and tools.