Company :Highmark WholecareJob Description : 

JOB SUMMARY

This job implements effective utilization management strategies including:  review of appropriateness of health care services, application of criteria to assure 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. This member base is all outpatient and it is UM of DME.

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.  Effectively 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.  Develops and sustains 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 - 5 years of related, progressive clinical experience in the area of specializationExperience in a clinical setting

Preferred

Experience in UM/CM/QA/Managed Care

LICENSES AND CERTIFICATIONS

Required

Registered Nurse (RN) license State of PA

Preferred

Certification in Utilization Management or a related field

SKILLS

Working knowledge of pertinent regulatory and compliance guidelines and medical policiesAbility to multi task and perform in a fast paced and often intense environmentExcellent written and verbal communication skillsAbility to analyze data, measure outcomes, and develop action plansBe enthusiastic, innovative, and flexibleBe a team player who possesses strong analytical and organizational skillsDemonstrated ability to prioritize work demands and meet deadlinesExcellent computer and software knowledge and skills

Language (Other than English)

None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Office-Based Positions
The employee, either for an office or work from home arrangement, generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours, including weekends and nights to provide coverage.

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)

Never

Physical work site required 

Yes

Lifting: up to 10 pounds

Rarely

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Rarely

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

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, 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, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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. 

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