Manager, Medical Review

Job ID: J122148
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 2, 2018

Share:

Description

GENERAL OVERVIEW:  

Oversee the development and maintenance of Medical Claims Review and Physician Advisor (PA) support staff daily operations by ensuring that all Medical Claims Review, appeals and physician advisor support activity complies with CMS, NCQA, URAC, DOH, DOL and various state specific regulatory requirements. Work closely with various internal and external customers to ensure compliance and efficiency in daily operations.  Responsible for communicating and executing corporate strategic initiatives. Collaborate with interdepartmental work groups, Compliance and Quality, Operations and Physician Advisors and Highmark’s Provider Network.

ESSENTIAL RESPONSIBILITIES: 

1.  Assure implementation and measurement of high performance standards meeting departmental and corporate performance and financial goals.

Provide direct reports and staff with guidance and educational tools in order to assure compliance with departmental audits.

Coordinate the development of the care management tools and processes required of an efficient and effective program.

In collaboration with other units and divisions, establish guidelines that quantify measurable care management value, benefit, and outcomes.

Coordinate and implement processes which require and enhance staff accountability.

2.  Identify, develop, and implement division/department projects which are focused on quality, utilization, process and/or outcome improvements.

Identify industry benchmarks through scientific research and literature searches on order to assure Medical Management & Policy exceeds industry standards.

Function in the role of project leader, and assure commitment and responsibility to the project’s success.

Represent Medical Management and Policy in various projects and corporate committees.

3.  Twenty-four hour accountability of Medical Claims Review and PA Support Operations.

Develop and implement processes which assure availability of staff related to either Medical Claims Review or PA Support.

Constantly evaluate the daily operations of Medical Claims Review and PA Support activity.  

Develop action plans which promote, support and improve claims review and appeal functions on an ongoing basis.

Develop and implement action plans designed to achieve and enhance compliance to accreditation standards.

Work in concert with all corporate divisions and departments to develop strategies supportive of the corporate mission and vision and strategic plan.

4.  Recruitment, selection, orientation, performance measurement; counseling, and performance improvement planning; promotion and termination per corporate policy; and career development and support of staff.

Develops employee performance goals that align with the corporate strategic plan.

Regularly scheduled staff meetings that assure timely corporate and operational communication are supported by meeting minutes; and provide an open forum for issues and problem solving.

Assure the development of teams which are focused on exceeding the identified 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 member.

Lead team to embrace a culture of change, high performance and talent development.

Develop staff to assume informal and formal leadership positions within the Highmark organization.

Uphold and demonstrate Highmark's mission and corporate values.

5.  This position displays effective communication skills while performing the following functions:

Maintain consistent and open lines of communication with internal and external customers.

Seek always to communicate changes in processes and programs order to enhance a share vision and mission.

Effectively communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners, and external customers.

Facilitate and lead informational and educational meetings for internal and external customers.

Participate in formal presentations within and outside of the corporation as related to Medical Claims Review and Provider Appeal activity.

6.  Other duties as assigned or requested.

III. QUALIFICATIONS:

Minimum

·Education level and/or relevant years of experience(s) in lieu of education:

  • High School Diploma/GED
  • Undergraduate clinical degree (such as nursing degree)
  • Minimum of 5 years clinical experience
  • Minimum of 5 years supervisory experience
  • Other requirements (licenses, certifications, specialized training, physical abilities needed to perform the job):
    • Current  state license appropriate for clinical training

Preferred

  • Minimum of 5 years’ experience in one of the following:  utilization management, managed care, claims review

Knowledge, Skills and Abilities 

  • 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
  • Ability to intervene in crisis situations and multi-task
  • Excellent computer and software knowledge and skills
  • Demonstrate proficient Project Management skills

IV. SCOPE OF RESPONSIBILITY 

Does this role supervise/manage other employees?  Yes   

If yes, indicate the number of direct reports:

V. WORK ENVIRONMENT

Is Travel Required?

Yes  

This job requires the ability to work as a team member. Additionally, this job requires the willingness and ability to report to work on a regular and timely basis and may require irregular work hours, holidays and/or weekends.

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

Share:

Interested in working at the Highmark Health enterprise?
Take the first step by joining our Talent Network today!

Join Our Talent Network

Similar Jobs

SVP, Post-Acute

Pittsburgh, PA, United States
Clinical Services

Sr Director LTSS

Wilmington, DE, United States
Clinical Services

Pharmacy Account Manager-DE/WV

Wilmington, DE, United States
Clinical Services

Pharmacy Account Manager-DE/WV

Parkersburg, WV, United States
Clinical Services

Wellness Engagement Specialist

Pittsburgh, PA, United States
Clinical Services

Enhanced Complex Care Manager RN

Pittsburgh, PA, United States
Clinical Services

LTSS Case Manager

Home, DE, United States
Clinical Services

Sr. Clinical Quality Management Consultant (Medicare)

Pittsburgh, PA, United States
Clinical Services

Care Manager - Medicare Advantage Appeals

Pittsburgh, PA, United States
Clinical Services

Manager Clinical Care Coordination

Home, DE, United States
Clinical Services

Wellness Engagement Specialist

Pittsburgh, PA, United States
Clinical Services

Medical Case Manager

Home, DE, United States
Clinical Services

Clinical Care Coordinator

Home, DE, United States
Clinical Services

Supervisor, Intake Coordination

Pittsburgh, PA, United States
Clinical Services

Vice President, Clinical Care & Wellness

Pittsburgh, PA, United States
Clinical Services

Medical Policy Clinician-3

Home, WV, United States
Clinical Services

Clinical Quality Management Analyst

Home, WV, United States
Clinical Services

Medical Case Manager

Home, DE, United States
Clinical Services

Intake Coordinator

Wilkes-Barre, PA, United States
Clinical Services

Associate Care Managerment Coordinator

Wilmington, DE, United States
Clinical Services

Medical Case Manager

Home, DE, United States
Clinical Services

Medical Case Manager

Home, DE, United States
Clinical Services

Medical Case Manager

Home, DE, United States
Clinical Services

Medical Case Manager- GHP

Pittsburgh, PA, United States
Clinical Services

Medical Case Manager RN or MSW

Pittsburgh, PA, United States
Clinical Services