Jobs at Point32Health

Supports chronic disease research studies through participant recruitment, data collection, database maintenance, data validation, cleaning, dataset creation, reporting, and technical documentation. Coordinates surveys and data collection tools, resolves data issues, supports internal and external collaborators, and contributes to project meetings and administrative research activities.

Coordinates healthcare appeals and grievances by assigning cases, processing mail, supporting analysts, tracking regulatory deadlines and effectuations, coordinating medical-record requests, distributing information, and reporting trends. The role requires careful prioritization, regulatory compliance, customer communication, basic medical terminology, data analysis, and proficiency with office and Windows applications. Work may occur remotely and occasionally require evening or weekend hours.

Leads clinical provider performance strategy, evaluation, KPI reporting, quality improvement, issue resolution, and performance planning. Oversees externally managed care and utilization management relationships, analyzes healthcare data, ensures compliance and quality standards, builds provider partnerships, and manages a team of performance specialists.

Coordinates implementation, maintenance, and administration of provider and vendor contracts across healthcare networks. Reviews contract terms, supports configuration testing and claims payment corrections, tracks milestones, resolves operational issues, maintains documentation, and assists with compliance, audits, and process improvement. The role requires cross-functional collaboration, strong organization, attention to detail, and the ability to interpret financial, legal, and operational contract requirements.

Leads negotiations with large physician and hospital organizations, managing financial, legal, regulatory, quality, and risk-sharing contract terms. Develops proposals, directs financial analyses, oversees contract documents, and partners with legal, clinical, reporting, and quality teams. Maintains provider relationships, communicates negotiation objectives to executives, ensures compliance with contracting strategy, and leads cross-functional efforts addressing contracting issues and negotiation tools.

Supports enterprise and market strategy development by analyzing healthcare industry trends, competitive dynamics, legislation, customer needs, and financial implications. Coordinates strategic planning initiatives, prioritizes projects, develops growth targets and value propositions, supports scenario planning, and tracks initiative effectiveness. Collaborates with executives, business leaders, subject matter experts, vendors, and external stakeholders to identify opportunities, resolve strategic issues, and communicate recommendations across the organization.

Leads network operations for a health plan, including provider contracting implementation, enrollment, credentialing, provider data integrity, and network strategy. Drives standardization, process optimization, digitization, and modernization across lines of business. Oversees provider operations, develops cross-functional relationships, manages strategic execution, and leads a high-performing team while engaging internal stakeholders and external provider partners.

Reviews clinically complex outpatient service requests for medical necessity and benefit coverage within regulatory timeframes. Performs utilization management determinations, collaborates with Medical Directors, communicates with providers and members, supports appeals, coaches letter writers, identifies utilization trends, and contributes to medical policy and process improvements. Requires independent clinical judgment, strong communication, and managed care expertise.

Administers and supports enterprise applications and middleware across multiple platforms. Responsibilities include system topology, availability and performance monitoring, high-availability deployments, troubleshooting, root cause analysis, disaster recovery planning, performance testing, documentation, requirements gathering, and cross-departmental project coordination. Provides production support and participates in on-call, weekend, and after-hours operations.

Supports public health research studies focused on drug safety and effectiveness by handling administrative tasks, grant and proposal support, data collection and database maintenance. Coordinates meetings, prepares agendas, presentations, protocols, research plans, reports, and minutes, while tracking timelines, deliverables, and action items. Collaborates with research teams and performs special projects in a health research environment.

Investigate and resolve first- and second-level healthcare appeals, research payment policies and changes, assess financial impacts, and maintain payment policy updates. Apply CPT, HCPCS, ICD-10-CM, benefits, reimbursement, and medical policy knowledge to support policy implementation, utilization decisions, and savings opportunities. Manage deliverables, meet deadlines, collaborate across departments, and mentor colleagues. The role requires healthcare-related education or equivalent experience, coding certification within one year, and knowledge of state and federal mandates.

Authors and edits clear, accurate staff documentation; ensures content integrity, formatting, and adherence to style standards. Leads knowledge management for projects, facilitates meetings, collaborates across departments, shares documentation best practices, and provides oversight for communities within the knowledge management system.

Lead negotiations with large physician and hospital organizations, managing financial, legal, regulatory, risk-sharing, quality incentive, and contract language terms. Develop proposals, direct financial analyses, oversee contract documentation, and ensure alignment with organizational contracting strategy. Partner with legal, clinical, reporting, and quality teams to establish negotiation objectives, communicate progress, and resolve contracting issues. Serve as the primary relationship contact for provider organizations and maintain negotiation tools or support functions.

Lead delivery of complex, high-risk Individual and Small Group product programs. Define portfolio strategy and roadmap, manage cross-functional teams and vendors, oversee P&L and financials, ensure operational readiness, and coach product managers to launch and evolve products across regional markets.

The Internal Controls Manager leads MAR and SOC reporting programs, ensuring compliance, audit readiness, and collaborating with Finance, IT, and external auditors to uphold control integrity.

Review and manage pharmacy prior authorization requests and coverage determinations, consult with medical directors on complex cases, communicate with members and providers, perform medication management and reconciliation for complex patients, support utilization management policy interpretation, liaise across departments, and participate in quality, risk management, and care coordination activities.

Leads the Cyber & Information Security portfolio and program governance for a healthcare organization. Oversees prioritization, dependencies, risks, budgeting, execution, reporting, process optimization, and executive visibility across security initiatives. Supports CISO and Board engagements, coordinates governance materials and follow-up, participates in business continuity exercises, advises leadership on operational risks, and mentors team members. Requires substantial experience managing complex technology or security programs in regulated environments.

Provide strategic leadership for provider partnership and network strategy, aligning contracting, product, clinical, operational, and finance goals. Oversee network, cost, and utilization analytics; design value-based payment and partnership models; grow and optimize networks for adequacy and regulatory alignment; monitor market and policy trends; drive execution of initiatives and sponsor governance, while leading and coaching director-level teams to deliver measurable results.

The Senior Business Data Analyst handles complex data analyses, collaborates with stakeholders, documents technical specifications, and develops data solutions to meet business objectives, ensuring quality and compliance.

Lead multiyear network product strategy and cross-functional teams to design, launch, and optimize health insurance network products. Drive compliance with state and federal regulations, financial modeling, portfolio performance monitoring, stakeholder engagement, vendor management, and go-to-market collateral and training to meet membership, profitability, and operational goals.