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J191693

PA Office Support Representative

Highmark Inc.

  • Company Highmark
  • Home, PA
  • Administrative Services
  • Full time
  • Day (United States of America)

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.


III. QUALIFICATIONS:

Minimum
•    High School Diploma / GED 
•    3-5 years of related, progressive experience. Exempted experience requirements effective August 2016.

Preferred
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?   

No   


V. WORK ENVIRONMENT


Is Travel Required?
No

JOB SUMMARY

ESSENTIAL RESPONSIBILITIES

EDUCATION

Required

Substitutions

  • 6 years of related and progressive experience in lieu of Bachelor's degree

Preferred

EXPERIENCE

Required

Preferred

LICENSES or CERTIFICATIONS

Required

Preferred

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

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Never

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 )

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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