Company :

　　Highmark Inc.

　　Job Description :

　　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

　　NoneSubstitutions

　　NonePreferred

　　Bachelor’s Degree in NursingEXPERIENCE

　　Required

　　3 - 5 years of related, progressive clinical experience in the area of specialization

　　Experience in a clinical setting

　　Preferred

　　Experience in UM/CM/QA/Managed CareLICENSES AND CERTIFICATIONS

　　Required

　　Active United States RN (Registered Nurse) license in any state is required upon hire. A WV license is required in addition to the home state license unless the home state license is part of the compact. The additional WV license must be obtained within the first 6 months of employment.Preferred

　　Certification in utilization management or a related fieldSKILLS

　　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

　　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:

　　$50,200.00

　　Pay Range Maximum:

　　$90,300.00

　　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 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 Law

　　Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )

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　　For accommodation requests, please contact HR Services Online at [email protected]

　　California Consumer Privacy Act Employees, Contractors, and Applicants Notice

　　Req ID: J236410