Highmark Inc.
Job Description : JOB SUMMARY This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives. ESSENTIAL RESPONSIBILITIES + Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline. + Function in accordance with applicable state, federal laws and regulatory compliance. + Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies. + Promote quality and efficiency in the delivery of care management services. + Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws. + Practice within the scope of ethical principles. + Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions. + Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes. Is familiar with the various care options and provider resources available to the member. + Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships. + Develop and sustain positive working relationships with internal and external customers. + Utilize outcomes data to improve ongoing care management services. + Other duties as assigned or requested EDUCATION Required + None Substitutions + None Preferred + Bachelor’s Degree in Nursing EXPERIENCE Required + 3 years of related, progressive clinical experience in the area of specialization + Experience in a clinical setting Preferred + Experience in UM/CM/QA/Managed Care LICENSES AND CERTIFICATIONS Required + Current RN state licensure required. Additional specific state licensure(s) may be required depending on where clinical care is being provided. Preferred + Certification in utilization management or a related field SKILLS + Working knowledge of pertinent regulatory and compliance guidelines and medical policies + Ability to multi task and perform in a fast paced and often intense environment + Excellent written and verbal communication skills + Ability to analyze data, measure outcomes, and develop action plans + Be enthusiastic, innovative, and flexible + Be a team player who possesses strong analytical and organizational skills + Demonstrated ability to prioritize work demands and meet deadlines + Excellent computer and software knowledge and skills Languages (Other than English) None Travel Requirement 0% - 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office-Based Teaches/trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Does Not Apply Works primarily out-of-the office selling products/services (sales employees) Does Not Apply Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely, Occasionally _Disclaimer:_ _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.__Compliance Requirement:_ _This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.__As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.__Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._ Pay Range Minimum: $50,200.00 Pay Range Maximum: $91,200.00_Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._ Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. 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