Company :Highmark Inc.
Job Description :
I. GENERAL OVERVIEW:
• Receive, review and make determinations regarding physician reviewer assignments for medical management decisions. Cases requiring physician review are provider and member requests, received from Medical Management & Policy (MM&P) and Member Grievance Departments.
• Responsible for management of Peer to Peer telephone line. Will handle calls in accordance with regulatory requirements.
• The timely assignment of cases in accordance with regulatory agencies’ standards including the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Committee (URAC), Pennsylvania Department of Health, Department of Labor, the Center for Medicare and Medicaid Services (CMS) and state specific regulations.
• Efficient communication and follow up with internal and external providers and contracted vendors.
II. ESSENTIAL RESPONSIBILITIES:
1. Responsible for the timely receipt, review and assignment of all incoming physician reviewer referrals and appeals to ensure that NCQA, URAC, CMS, DOH, DOL and state specific regulatory compliance standards are met. (40%)
2. Responsible for the timely and efficient management of the physician peer to peer telephone line, including follow up with providers and provider office staffs to clarify and request information and provide follow up as necessary.The management of the peer to peer telephone lines includes:
• the timely, accurate assignment of requests to internal physician reviewers/medical directors
• the timely, accurate entry of requests into the database for reporting purposes (20%)
3. Responsible to efficiently coordinate the clinical review process with contracted external review companies in accordance with all regulatory guidelines. This includes:
• the submission and receipt of clinical information
• effective communication with the external review liaison to address questions or issues
• The efficient and accurate recording of all case information submitted for external review (20%)
4. Responsible for the timely sorting and filing of all required case information. (10%)
5. Responsible for data entry, maintenance and integrity of all databases. (10%)
6. Other duties as assigned or requested.
• High School Diploma / GED
• 3-5 years of related, progressive experience. Exempted experience requirements effective August 2016.
Additional relevant education level and/or years of experience:
• Experience in navigating managed care system
• Certification or equivalent training in Word Processing, Database Management or Medical Terminology
Knowledge, Skills and Abilities
• Ability to multi task and perform in a fast paced, and often intense environment
• Excellent written and verbal communication skills
• Be enthusiastic, innovative and flexible.
• Ability to make decisions that are consistently accurate
• Proficient in navigating through Highmark systems.
• 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
• The incumbent must be able to function interact with all members of the health care team, both internal and external.
• This incumbent requires the willingness and ability to report to work on a regular and timely basis and may require working irregular hours, holidays, and/or weekends.
• Ability to analyze data, measure outcomes and develop action plans.
IV. SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
V. WORK ENVIRONMENT
Is Travel Required?
- 6 years of related and progressive experience in lieu of Bachelor's degree
LICENSES or CERTIFICATIONS
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.
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 )
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