Job ID: J131437
Company: Highmark Health
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Oct 2, 2018
This job leads the Inpatient Care Management Program for the department, which includes management of RN care managers, Behavioral Healthcare Managers, and Administrative Support staff. This includes the administration and management of assigned, select utilization management (UM) activities for the organization, including concurrent review, review of urgent and urgent admissions, continued stay review in all facilities assigned and discharge planning. It may include any future affiliations with an inpatient UM program. This job requires expertise in the areas of utilization management (UM), benefit interpretation, insurance industry regulations/compliance standards and personnel management. Accountable for the operational excellence of the unit, control of administrative and care cost initiatives, system development and delivery of high quality outcomes, compliance with all state and federal regulations that affect UM activities and any needed reporting in a complete and timely manner. Ultimately responsible for compliance with NCQA, URAC, CMS, DOH and DOL regulations as related to UM activities. Coordinates all inpatient care management activities to achieve and sustain operational excellence. This is achieved through a collaborative approach with the management team to deliver an exceptional customer experience that promotes and facilitates appropriate resource utilization in the most appropriate care setting. Staff supervised by this individual may have relationships with a geographically aligned and assigned team responsible for population health management.
Bachelor's Degree- Nursing (BSN)
Health or business related field.
KNOWLEDGE, SKILLS & ABILITIES (List the attributes required to perform the job through demonstrated service, education or training)
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
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