Job Details

Job Title

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

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.

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Req ID: J274597