Manager, Utilization Review

Job ID: J117053
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at:




This job requires expertise in the areas of Utilization Management, Continuum of Care Planning, Benefit Interpretation, Insurance Industry Regulations as well as Personnel Management. The incumbent is accountable for the oversight; development and maintenance of the department's utilization management processes which includes strategic planning, care cost initiatives, system development and quality outcomes.  Responsible for compliance to NCQA, URAC, CMS, DOH, and DOL regulations. Coordinates all department activities; staff education, policy and procedure development and revision, care audits, oversees overall operations such as call volumes, referrals to disease management programs and quality assurance. Responsible for appropriate application of Medical Policy and criteria. Communicates and executes corporate initiatives. Manages and controls departmental expenditures defined by cost center allocation.


  • Develop, implement, and measure department, corporate, and utilization management objectives.
  • Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity per corporate policy.
  • Constantly evaluate the utilization management markets and incorporate the needs of the healthcare environment into the utilization management programs.
  • Ensure the development of teams which are focused on exceeding the utilization management objectives through team building sessions, team work facilitation, committee opportunities and leadership opportunities.
  • Develop and coordinate cross-functional/interdepartmental relationships which enhance the overall care delivery and outcomes for our customers.
  • Uphold and demonstrate Highmark's mission and corporate values.
  • Assist in the analysis of clinical data elements and present data analysis to a wide range of audiances
  • Assure implementation and measurement of high performance standards.
  • Provide direct reports with guidance and educational tools in order to assure compliance with a minimal individual audit score that meets department standards.
  • Coordinate the development of the utilization management tools and processes required of an efficient and effective program.
  • In collaboration with other units and divisions, establish guidelines that quantify measurable utilization management value, benefit, and outcomes.
  • Coordinate and implement processes which require and enhance direct report accountability.
  • Assure that direct reports achieve the minimal qualification of their positions through ongoing staff development, counseling, and guidance.
  • Describe and document outcomes in the Program Description for presentation at the Care Management Committee
  • Daily accountability for triage, crisis intervention and referral activities.
  • Identify, develop, and implement division/department projects focused on quality, utilization, process and/or outcome improvements.
  • Identify industry benchmarks through scientific research to assure operations exceed industry standards.
  • Function in the role of project leader demonstrating commitment and responsibility to the project’s success.
  • Represent the department by participation throughout the corporation on projects and committees.
  • Manage multiple projects and effectively communicate relevant project information to leadership.
  • Delver engaging, informative and well organized presentations.     
  • Develop and implement processes which assure 24-hour availability of utilization management expertise.
  • Develop action plans which promote, support and improve utilization management functions on an ongoing basis.
  • Develop and implement action plans designed to achieve and enhance compliance to accreditation standards in accordance with NCQA, URAC, CMS, DOH, and DOL regulations.
  • Work in concert with all corporate divisions and departments to develop strategies supportive of the corporate mission and vision.
  • Assessing and recommending budget requirements and responsible for budget preparation to cost-effectively and efficiently operate departmental programs. 
  • Monitor monthly budget for variances, initiating cost savings while maintaining highly efficient operations.
  • Other duties as assigned or requested.



  • Active United States Registered Nurse (RN) license
  • 7 - 10 years in the Insurance or related industry
  • 3 - 5 years of Clinical experience


  • Master’s Degree in a related Human Services field
  • 3 -5 years in Management
  • Experience in Project Management


  • Demonstrated Project Management skills
  • Excellent written and verbal communication skills
  • Ability to interact with all levels of the organization
  • Ability to interact with external customers and providers
  • Ability to analyze data, measure outcomes and develop action plans
  • Highly effective interpersonal skills
  • Recognized as a clinical expert
  • Ability to intervene in crisis situations and multi-task.
  • Excellent computer and software knowledge and skills

Referral Level: 4

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.
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