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Point32Health Service Resolution Specialist in Canton, Massachusetts

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

Under the direction of the Manager of the Sales Support Team in Member Experience, the Member Experience, Sales Support Specialist is responsible for providing accurate and thorough interpretation of Tufts Health Plan benefits, payment policies, claims processes, eligibility and enrollment policies to members, providers, employers, and internal customers, specifically the Sales and Service Department. The Sales Support Specialist independently provides education and support regarding operational aspects of all Tufts Health Plan products as deemed appropriate. This includes, but is not limited to, contacting members or providers regarding THP policy/procedures, disseminating information, identifying and resolving complex claim issues, handling escalated issues, and performing off-site visits based on employer or provider needs. The Sales Support Specialist will forward any feedback from members, employers or providers on the impact of plan operations, policies and procedures and communicate this information to the Member Experience Management Team.

Key Responsibilities/Duties – what you will be doing

Address day-to-day inquiries from internal departments (including but not limited to Sales & Service Department and Senior Management) members, providers and employer groups. Perform outbound call assistance to members, providers and employers, providing excellent customer service, thorough explanation of issues and resolution as well as accurate and complete documentation of complex issues, on behalf of internal department customers.

Act as the primary resource to internal and external customers by obtaining appropriate background information to assist and oversee the troubleshooting and resolution of all inquiries. Requires performing and/or coordinating of related research activities and involving other departments as needed in order to effectively address issues presented. This may include, but is not limited to, benefit, enrollment and eligibility issues, ongoing claims and reimbursement issues, post-settlement issues and trends, clarification of plan policy and procedure, education of members, providers or employers, administrative complaints, etc.

Proactively communicate with employers and providers and their office staff or members through oral and written communications and targeted visits to promote an understanding of benefit interpretation, claims & reimbursement issues, referral management, general billing issues, benefit interpretation, and overviews of internal departments as needed.

Provide ongoing Service Resolution support and, as necessary, facilitate communications via telephone, email or face-to-face meetings with members, employers or providers and/or internal departments to effectively address individual customer concerns related to Plan operations, claims procedures, new programs or products and special contracted services.

Maintain documentation of logs, status reports, all correspondence, meeting minutes, and any other pertinent documentation via MACESS, Microsoft Access, Microsoft Word, and Microsoft Excel for tracking and reporting purposes.

Qualifications – what you need to perform the job

A minimum of two years of experience in a managed care/health industry environment required. In addition, a minimum of 1 year Member or Provider Services Call Center experience is preferred. Excellent verbal and written communication skills, generally acquired through college or other advanced education are required. Knowledge of medical terminology is preferred.

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.

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.