Company :
Highmark Inc.Job Description :
JOB SUMMARY
The job conducts and documents thorough investigations of Part C, Part D, QIO and Administrative Law Judge Case Types, communicating resolution to members in accordance with Center for Medicare and Medicaid Services (CMS) requirements. Requires broad knowledge of plan products, medical policy requirements, processes and enrollment rules. Responsible for all aspects of Part C and D clinical appeals , up to and including decision making, considering potential impacts to regulatory compliance as well as CMS star ratings. Provides support to non-clinical appeals and ensures correct authorization of services.
ESSENTIAL RESPONSIBILITIES
- Complete and document thorough clinical investigation of all Part C, Part D, QIO Home Health and ALJ appeals. Perform research, request and review all related relevant documentation and assemble case file. Ensure accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements. Ensure effective and compliant effectuation of appeals.
- Review outcome of appeal, either independently or in conjunction with medical director. Communicate effectively with members, providers, and colleagues, successfully articulating issues, problems and solutions.
- Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies.
- Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies
- for improvement.
- Ensure quality assurance of appeal work, assist in development of desktop procedures and/or training materials.
- Other duties as assigned or requested.
EDUCATION
Required
High School/GED
Substitutions
None
Preferred
Bachelor's in Nursing
EXPERIENCE
Required
- 3 years Clinical Nursing
Preferred
- 3 years Appeals Review
- 3 years Utilization Management Review
- 3 years Regulatory Compliance
LICENSES or CERTIFICATIONS
Required
- PA RN License
-
WV RN License (within 3 months after hire)
Preferred
- None
SKILLS
- Critical Thinking
- Organization
- Time Management
- Decision Making
- Written Communication
- Cross-Functional Collaboration
- Microsoft Word
Language (Other than English)
None
Travel Requirements
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
Does Not Apply
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Frequently
Lifting: 10 to 25 pounds
Never
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 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 )
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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
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