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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 State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). 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:
$68,400.00Pay Range Maximum:
$105,900.00Base 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.
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