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J181537

Supervisor Utilization Management

Highmark Inc.

  • Company Highmark
  • Home, DE
  • Clinical Services
  • Full time
  • Day (United States of America)

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This job manages a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Manages areas which may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting. Utilizes the applicable medical policy and industry standards, and accurately interprets benefits and managed care products. The incumbent is accountable for the oversight; development and maintenance of the department's care management processes. This includes utilization management, strategic planning, care cost initiatives, system development and quality outcomes. Hires, trains, coaches, counsels, and evaluates performance of direct reports. The incumbent is responsible for compliance with NCQA, URAC, CMS, DOH, and DOL regulations. Also responsible for appropriate application of medical policy and criteria. Works closely with claims, service, Provider Relations, HMS and other departments within the corporation to resolve issues and ensure activities coincide with Utilization Management processes.   

ESSENTIAL RESPONSIBILITIES

  • Manage and coordinate all department activities; staff education, policy and procedure development and revision, individual staff audits, oversee overall operations to ensure compliance to standards and referrals to case management and physician advisor area.
  • Role model to staff and assist in the day to day activities as needed.
  • Provide service support, training and performance statistics to the team in addition to initiating and implementing process improvements.
  • Perform management functions including, but not limited to: recruitment, selection, orientation, performance measurement; counseling, and performance improvement planning; promotion and termination per corporate policy; and career development and support of staff.
  • Apply clinical knowledge to work with facilities and providers for care-coordination. May also manage appeals for services denied.
  • Conduct staff meetings that ensure corporate and operational communication supported by meeting minutes; and provide an open forum for issues and problem solving.
  • Set appropriate targets, measure outcomes and establish plans to negate variances in quality, staff retention, finance and customer satisfaction.
  • Provide direct reports with guidance and educational tools in order to ensure compliance with NCQA, URAC, DOH, DOL and CMS.
  • Review and provide input into the oversight of policies and procedures to support regulatory requirements related to Utilization Review.
  • Develop and implement appropriate audit requirements in order to ensure compliance with all staff activity related to Utilization Review. 
  • Ensure that all staff achieves the minimal qualification of their position through ongoing staff development, counsel and motivate employees, evaluate employees, investigate complaints or performance concerns; implement disciplinary action as needed and in consultation with appropriate authority and Employee Relations.
  • Maintain consistent and open lines of communication with internal and external customers.
  • Communicate changes in processes and programs order to enhance a share vision and mission.
  • Communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners, and external customers.
  • Facilitate and lead informational and educational meetings for internal and external customers.
  • Accountable for special projects and enhanced activities within the department.
  • Participate in the development and implementation of department/division projects.
  • Implement integration processes and planning activities.
  • Other duties as assigned or requested.

EDUCATION

Required

  • Bachelor’s Degree

Substitutions

  • None

Preferred

  • Master’s Degree in Business Administration/Management or related Healthcare field

EXPERIENCE

Required

  • 5 - 7 years in a Clinical setting
  • 3 - 5 years in Utilization Management or Managed Care

                    

Preferred

  • None

LICENSES AND CERTIFICATIONS

Required

Current license in one or more of the following disciplines:

  • Registered Nurse (RN)
  • Licensed Clinical Social Worker (LCSW)
  • Licensed Social Worker (LSW)
  • Licensed Professional Counselor (LPC)
  • Other related Clinical License

Preferred

  • None

SKILLS

  • Experience in workforce development and resource management with excellent team building and professional development skills
  • Must demonstrate excellent leadership skills and be able to relate to all levels of management and staff as well as individuals external to the corporation.
  • Experience in staff/project management
  • Strong leadership, collaboration, l and motivational skills
  • 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.
  • Team player that possesses strong analytical and organizational skill
  • The ability to prioritize work demands and meet deadlines
  • Excellent 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

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Frequently

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

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.

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. 

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 )

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 HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice


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