Company :Highmark Inc.
Job Description :
This job is responsible for the strategic vision for the Utilization Management (UM) non-clinical team, including driving continuous process improvement activities to enhance performance and reduce administrative costs and identifying opportunities to manage care costs in a more effective manner. The incumbent oversees and manages a team that governs the day to day activities of the Non-Clinical UM staff which includes the monitoring of workflow, resource reallocation and process compliance. This team services all lines of business (commercial and Medicare Advantage). This team is responsible for inquiry queues for internal and external customers to facilitate members receiving medications and services in a timely manner according to service level agreements. Ensures compliance with all regulatory requirements, including CMS, DOL, DOH, state specific requirements, NCQA and URAC. The incumbent manages and coordinates change management activities, ensuring all stakeholders and staffs are effectively absorbing organizational change while maintaining excellent operational results.
- Manage a team of supervisors who oversee and govern the day to day activities of non-clinical Medical and/or Pharmacy team members which includes the monitoring of workflow, resource reallocation and process compliance. This team services all lines of business (commercial and Medicare Advantage) and is primarily responsible for the identification of provider or member requests, obtaining the necessary demographic information, providing general information and determining the appropriate outcomes for encountered situations.
- Interview, select, train, counsel, evaluate and possess disciplinary action of departmental employees. Responsibilities include creation and establishment of goals and objectives of the unit. Human Resource management, affirmative action, diversity, quality management and overall monthly reporting of performance of the unit required.
- Work closely with the internal partners across the Health Plan and vendors to maintain operational processes and collaborate on workflow initiatives.
- Play a vital role in the management/coordination of activity and decision-making to ensure that day to day operational decisions are made to contain administrative cost to minimize risk and to achieve maximum output and performance.
- Orchestrate internal processes and initiatives with Utilization Management to drive process standardization, performance measurement and shaping of organizational culture.
- Produce materials, information tool kits, communication materials required to support change management efforts, In collaboration with the project managers and other key partners, . This could include support for special events, training events, department web and/or SharePoint content, senior management materials, coordinate production of slide presentations and other audio visual assignment with creative services and corporate communications.
- Other duties as assigned or requested.
- Bachelor’s Degree
- 6 years of applicable business experience in lieu of a Bachelor's Degree
- 3 years in a Call Center in a regulated industry
- 3 - 5 years in a management role
- 3 years in the Healthcare Insurance Industry
- 3 years utilizing Medical Terminology and Coding
- 3 years with UM regulations (e.g. DOH, DOL, CMS, NCQA, URAC)
- 3 years in a Professional and/or Hospital setting
- Training in product lines of business and medical management
- Registered Nurse or Social Worker preferred
LICENSES AND CERTIFICATIONS
- High Standard of professional conduct
- Excellent verbal and business writing skills
- Ability to maintain confidential information
- PC/Mainframe application skills
- Experience in team interactions and team facilitating
- Ability to quickly identify and provide recommendations on issues
- Excellent team building and professional development skills
- Solid negotiation and influencing skills across sales, technical and operations partners
- 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
- Prior experience or demonstrated knowledge of Process Improvement
- Ability to drive and execute change and process innovation
- Knowledge of Insurance Industry practices
Language (Other than English):
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
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 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.
Referral Payout Level 2
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.
EEO is The Law
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