Company :Highmark Inc.
Job Description :
Perform accurate and timely processing of pre-certification requests for authorization of medically necessary health care services at the appropriate level of care, based on the benefits for the line of business, and in compliance with Gateway policies, procedures and regulatory requirements. Document, process and route requests for services to the nurse reviewer and other departments based on documentation procedures, including review type, clinical information, and decision timeframes. Follow policies and procedures to assure case completion and compliance with state and federal regulatory agencies. Maintain or exceed department standards for call volume, response time and related production and quality measures. May interact with other departments and providers to resolve cases.
- Communicate effectively
- Proactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are met
- Communicate effectively with Utilization Management Staff, providers, other internal and external customers and management
- Route Cases Based on Established Guidelines
- Provide accurate and timely routing of service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelines
- Process service requests meeting established guidelines, and document and route requests that are not permitted
- Request additional information verbally and in writing when the information provided is not adequate to make a medical necessity determination
- Maintain or exceed department call center standards
- Adhere to line of business phone standards to assure regulatory requirements are met
- Utilize phone functions to monitor the number of calls in queue and wait time
- Utilize daily phone standard reports to assess opportunities for self improvement
- Meet or exceed standards for other production and quality measures
- Other duties as assigned or requested.
- High School Diploma / GED
- Experience in customer service
- Experience in typing, keyboard and computer skills
- Work experience in medical terminology
- Associates degree or certification in a health related occupation
- Work experience with ICD-9 and/or CPT coding
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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