Location: Canton,MA, USA
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. To learn more about who we are at Point32Health, click here .
Job Summary
The Director, Utilization Management is responsible for directing, leading, and modifying the business processes and operations for all levels of utilization management review (i.e., Precertification and Intake Services, Inpatient & Outpatient) for Point32Health's lines of business. The Director is responsible for ensuring achievement of Point32Health corporate goals; compliance with Point32Health business rules; oversight of all aspects of outpatient services utilization management; and development, implementation and refinement of effective business processes that support compliance with relevant regulatory requirements (such as CMS, DOI, NCQA, ACA, USFHP and/or ASO/ERISA). The Director is expected to strategically develop and effectively deploy solutions in support of corporate and division specific goals. She/he will do so in an engaged and professional manner within and through a matrixed business environment. The Director will collaborate with division and enterprise business and medical leadership to drive clinical and/or operational initiatives. The Director is expected to collaborate with other Health Care Services peers / leaders, Operations and/or divisional department clinical leaders (such as the divisional CMO, Medical Directors, Directors and/or business leads), plan medical staff and key provider – facility and physician or group – clinical leadership. The Director oversees and leads medical management activities related to precertification utilization management and discharge planning for acute inpatient, LTAC (Long-term Acute Care), rehabilitation and skilled nursing services. The Director ensures initiatives are on schedule and within budget, and guides strategy, policies, and protocols in accordance with organizational strategy. The Director will ensure collaboration and coordination with enterprise or divisional based behavioral health and / or case management leaders and programs. The Director assumes a leadership role with internal and external customers to achieve optimal clinical and resource outcomes.Key Responsibilities/Duties – what you will be doing
oversee and lead the precertification management and related authorization management operations for Commercial, Senior and Public Plans (MassHealth and QHP (Qualified Health Plan)) products.
Qualifications – what you need to perform the job
Education, Certification and Licensure
Experience (minimum years required):
Skill Requirements
The ideal candidate will be a high energy personality type who can mobilize a staff around a goal or set of goals and achieve it; is able to sustain high levels of activity over long hours when necessary and has the mental energy to constantly seek better alternatives. Requires focus on process engineering and improvement; discern larger patterns and relationships from smaller components and develop and implement work plans through to application.
Frequent contact with senior leadership, physicians, managers, and peers necessitates excellent interpersonal and communication skills. A high level of diplomacy is necessary to anticipate, recognize, and deal effectively with politically sensitive issues. Excellent leadership skills are needed to guide and inspire others; encourage high standards and exemplify those standards; command attention and respect. Role requires change management and team engagement skills, including the ability to build coalitions across disciplines and departments throughout the company.
Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.
Compensation & Total Rewards Overview
As 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 andbenefits remains in the Company's sole discretion and maybe 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
Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity
Point32Health 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.
Scam Alert : Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact ...@point32health.org
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