Job Opportunity At Highmark Inc.
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.
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.