Company :Highmark HealthJob Description :JOB SUMMARYThis job works directly with network providers to support key clinical transformation programs with a focus on utilization of appropriate care. The team member works with internal and external stakeholders to ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. The team member will also work with providers to identify specific areas of improvement within the same domain and help providers develop meaningful action plans to improve performance. The team member is responsible for building relationships, engaging clinicians, educating on Utilization Management policies and processes, developing workflows and resources, and improving provider performance.ESSENTIAL RESPONSIBILITIES
Review provider performance according to accepted and established criteria, as well as other approved guidelines and medical policies.
Analyze qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction.
Educate providers and other relevant external stakeholders on medical policy clinical criteria used to authorize care on a proactive basis.
Develop and sustain positive working relationships with internal and external customers.
Respond to customer inquiries and offers interventions and/or alternatives.
Other duties as assigned or requested.
EXPERIENCERequired
5 years experience in any of the following healthcare areas:the provider environment (hospital, facility, PCP, specialist, supporting area(s)), or healthcare insurance industry, or healthcare administration in a provider office, hospital and/or health systems, or healthcare consulting in provider setting.
3 years of experience in utilization management/care management/QA/managed care
Preferred
3 years of experience in data analysis, interpretation, and outcomes strategic plan development.
1 year of lean, six sigma, TQI, TQC or other quality and/or project management certification
SKILLS
Ability to analyze data, measure outcomes, and develop action plans
Working knowledge of pertinent regulatory and compliance guidelines and medical policies
Ability to multitask and perform in a fast-paced and often intense environment that requires flexibility
Excellent written and verbal presentation skills, excellent interpersonal and negotiation skills, and ability to positively influence others.Engages with external stakeholders with a professional demeanor and customer-centered mindset.
Be a team player who possesses strong analytical and organizational skills.
EDUCATIONRequired
Bachelor’s degree in nursing OR licensed RN with associate's degree or RN diploma.
Preferred
None
LICENSES or CERTIFICATIONSRequired
Registered Nurse (RN) license in PA; additional states may be required.
Preferred
PA Driver's license
Certification in nursing area of expertise
Language (Other than English):NoneTravel Requirement:0% - 25%PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition TypeOffice- or Remote-basedTeaches / trains othersOccasionallyTravel from the office to various work sites or from site-to-siteRarelyWorks primarily out-of-the office selling products/services (sales employees)NeverPhysical work site requiredNoLifting: up to 10 poundsConstantlyLifting: 10 to 25 poundsOccasionallyLifting: 25 to 50 poundsRarelyDisclaimer: 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 job 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:$57,700.00Pay Range Maximum:$106,700.00Base 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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.EEO is The LawEqual Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migratedfiles/employers/posterscreenreaderoptimized.pdf )We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.For accommodation requests, please contact HR Services Online at [email protected] Consumer Privacy Act Employees, Contractors, and Applicants NoticeReq ID: J243232