Care Manager - Medicare Appeals

Job ID: J111566
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at:

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Description

JOB SUMMARY

This job implements effective utilization management strategies including:  review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues.  Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction.  Responds to customer inquiries and offers interventions and/or alternatives.

ESSENTIAL RESPONSIBILITIES

  • Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline.
  • Function in accordance with applicable state, federal laws and regulatory compliance.
  • Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
  • Promote quality and efficiency in the delivery of care management services.
  • Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework  of applicable laws.
  • Practice within the scope of ethical principles.
  • Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
  • Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes.  Is familiar with the various care options and provider resources available to the member.
  • Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
  • Develop and sustain positive working relationships with internal and external customers.
  • Utilize outcomes data to improve ongoing care management services.
  • Other duties as assigned or requested.

QUALIFICATIONS

Minimum

  • Active United States RN (Registered Nurse) license
  • 3 - 5 years of related, progressive clinical experience in the area of specialization
  • Experience in a clinical setting

Preferred

  • Bachelor’s Degree in Nursing
  • Experience in UM/CM/QA/Managed Care
  • Certification in utilization management or a related field

SKILLS

  • Working knowledge of pertinent regulatory and compliance guidelines and medical policies
  • Ability to multi task and perform in a fast paced and often intense environment
  • Excellent written and verbal communication skills
  • Ability to analyze data, measure outcomes, and develop action plans
  • Be enthusiastic, innovative, and flexible
  • Be a team player who possesses strong analytical and organizational skills
  • Demonstrated ability to prioritize work demands and meet deadlines
  • Excellent computer and software knowledge and skills

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.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.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 call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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