Jobs at Point32Health

Leads moderately complex to complex healthcare fraud, waste, and abuse investigations involving provider research, data analysis, medical record review, and interviews. Applies healthcare laws, regulations, coding and coverage rules, prepares investigative reports, recommends corrective actions, supports overpayment recovery, and monitors providers. Collaborates with analytics, intake, SIU management, and business units to identify emerging schemes, refine data mining, educate stakeholders, and prevent future losses.

Analyzes HR data from HRIS, ATS, performance systems, and surveys; builds people metrics, dashboards, reports, and statistical models; identifies workforce trends; and provides recommendations to improve recruiting, onboarding, training, performance management, and other HR programs. Partners with HR business leaders, supports surveys and ad hoc requests, and communicates findings through presentations and data visualizations.

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.

Provides MassHealth and Medicare eligibility guidance and enrollment assistance to seniors, adults with disabilities, caregivers, and members. Conducts outreach, presentations, referrals, application and renewal support, documentation follow-up, and lead generation for SCO and One Care programs. Maintains CRM records, tracks applications through MMIS or the MassHealth Enrollment Center, supports redeterminations, meets enrollment goals, and coordinates with internal teams and community partners while serving diverse populations.

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.

Lead enterprise underwriting and pricing strategy for large and small group business. Develop rates, underwriting policies, tools, and stop-loss management; direct underwriting operations, analytics, vendor and sales support, and team leadership to balance market penetration and profitability while ensuring regulatory compliance.

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.

Lead month-end and quarter-end close for multiple health plans; manage accounting staff; prepare GAAP and NAIC statutory financials and tax filings; coordinate external audits; develop technical accounting policy and internal controls; support regulatory compliance and special financial reporting projects.

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.

As Vice President of Affordability, you will lead the enterprise strategy to reduce the Total Cost of Care, influence senior executives, and collaborate across departments to improve healthcare affordability and performance.

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.

The Senior IT Internal Auditor evaluates internal controls, assists with audits, prepares audit workpapers, and ensures completion of management action plans.

Lead design, development, and implementation of advanced ML and NLP models for payment integrity. Translate business problems into analytics, run large-scale experiments, automate analyses, validate and operationalize models, and present actionable insights. Manage multiple projects, mentor junior staff, and enforce governance, ethical norms, and scalable processes to improve quality, member experience, and cost outcomes.

Manage stop‑loss reinsurance for self‑funded health plans by validating monthly premium, claims, and reimbursement data; investigate and resolve variances; coordinate settlement/surplus reporting and month/period‑end close activities; maintain reinsurance mailbox, SOPs, filings, and audit support; liaise with vendors and cross‑functional teams; prepare and maintain reports, ensure compliance with reinsurance agreements, and drive timely, accurate reconciliations and documentation.