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Utilization Mgmt Clinician

Highmark Inc.

  • Company Highmark
  • Home, NY
  • Clinical Services
  • Full time
  • Day (United States of America)

Company :

Highmark Inc.

Job Description : 

Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.
Performs either pre or post service review for medical necessity utilizing criteria, medical policy and submitted medical information. Prepares any case that does not meet medical necessity to submit to a Medical Director. Post review, informs member, MD and/or facility of the decision in a written document and/or an oral response. May prepare various correspondences including Initial Adverse Determination, Final Adverse Determination, approval or a Last Covered Day within required time frame guidelines. Utilizes multi computer applications to effectively perform duties.
Triages provider requests to comply with regulatory requirements; applies appropriate timeframes to meet regulatory requirements for requesting medical records or sending out the decisions. Maintains compliance with HIPAA (Health Insurance Portability and Accountability Act) for all work.
Utilizes and applies knowledge and understanding of CPT procedure codes, HCPC (DME) codes and ICD (Diagnosis) codes in performance of duties.
Travel and communication with facilities and Provider community, in the course of duties, as necessary.
Performs other related duties as required.

Education/Experience/Skills Requirements
Required Education: Required Experience:

Completion of nursing diploma or Associate’s Nursing program required. BSN preferred.  Minimum three (3) years of clinical experience required.

CCM (Certified Case Manager) preferred.

Required Knowledge/Skills:
1. Excellent time management skills with the ability to multitask and be flexible based on department needs
2. Public communication and presentation skills
3. Computer applications; including but not limited to: Microsoft Office applications
4. Excellent organizational skills and attention to detail
5. Excellent verbal and written communication skills
6. Strategic thinking/planning skills and ability to work effectively with minor supervision
7. Polished, professional image and reputation. Demonstrated personal accountability.
8. Must be able to work in a fast-paced team environment with daily work processing under highly regulated deadlines
9. High degree of business maturity and demonstrated confidentiality
10. Effective oral and written communication skills. Ability to prepare accurate and timely documentation.

Required Licenses/Certifications:
New York State Registered Nurse

Problem Solving
Managerial/Supervisory Responsibilities
Does this Position have Supervisory Responsibility? No
Number of Emps Supervised:
Titles of Employees Supervised:
Financial/Budgetary Responsibilities:
Other Job Specifications:
External Contacts: UM tasks and actions require interaction with provider offices, facilities, vendors, member and external regulatory agencies.
Working Conditions/Physical Demands:
Position requires:
* Must be able to accommodate local travel. Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record)
* Irregular hours
* Must be able to accommodate alternate shifts/days
* Must be able to occasionally attend off-site meetings, events, conferences
* Must be able to work in an office environment
* Must have ability and access to work from remote location such as home
Position involves:
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
* Physical Effort: Minimum; typical of most office work. Mostly sedentary work.
* Prolonged Sitting
* Reaching
* Repetitive Motion
* Vision Req: Close vision (clear vision at 20 inches or less)
* Vision Req: Distance (clear vision at 20 feet or more)
* Walking
* Weight: lift/carry/push/pull under 10 lbs.

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.

Pay Range Minimum:


Pay Range Maximum:


Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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 ( )

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