**Job Description :**
This job manages utilization management daily operations to ensure medically necessary services are provided in a timely, cost effective and quality manner, and at the appropriate level of care. Manages the daily operations Utilization Management (UM) to ensure the components of the Highmark's UM program are implemented in a proactive, collaborative and consistent manner. Participates in the development of the plan to effectively execute the UM components of Highmark's Strategic Plan.
+ Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
+ Communicate effectively and accurately with Highmark managers, directors, direct reports, other internal customers and external customers taking into consideration the Utilization Management department and corporate goals, business needs, and guided by the Highmark Health mission and value statements.
+ Manage utilization management operations, and communicate effectively the impact utilization management processes have on the overall operations of Highmark.
+ Develop, implement, and monitor work processes to ensure that medically necessary services are provided in a timely, cost effective, and quality manner and at the appropriate level of care.
+ Solve complex business issues as identified and include coordination throughout all levels of the department to facilitate an effective and timely resolution.
+ Implement changes to improve UM processes, operations, and care delivery systems based on results of the member and provider satisfaction surveys, and implement, manage, and monitor the application of licensed medical criteria to ensure consistent review decision outcomes.
+ Interpret federal and state regulations and assess the regulatory requirements and NCQA standards for applicability to UM policies and procedures and implement processes to meet the requirements.
+ Comply with regulations that impact on UM procedures and develop and implementprocesses that comply with all regulatory bodies, which include but are not limited to, Centers for Medicare and Medicaid Services (CMS), Department of Public Welfare (DPW), Pennsylvania Department of Health (DOH), and the National Committee on Quality Assurance (NCQA) for all lines of business.
+ Plan, implement, and assess audit functions and results for continuous process improvement and develop corrective action plan as needed to ensure compliance and understand the potential for sanctions and/or adverse financial impact resulting from non-compliance with federal and state regulatory, and National Committee on Quality Assurance (NCQA) requirements.
+ Review all audit results to assess individual employee and team performance for opportunities for additional training to improve adherence to utilization management policies, procedures, and processes.
+ Evaluate reports to ensure that UM processes are consistent with corporate and departmental objectives, and implement process improvements when reports indicate that processes may not be aligned with goals, objectives and the strategic plan.
+ Develop and utilize reports to monitor and determine utilization trends in order to implement strategies to provide quality, cost-effective care in the most appropriate setting.
+ Assess data from reports to determine opportunities to modify work processes, enhance efficiency, ensure work assignments are equitable, and allocate resources where there is opportunity to impact utilization outcomes.
+ Other duties as assigned or requested.
+ Bachelor's Degree in Nursing
+ RN with 4 years of clinical and manage care experience, with responsibility for supervision or coordination or oversight and quality improvement of department functions, in lieu of BSN
+ Master's Degree in Nursing
+ 5 years in Utilization Review/Management
+ 3 years as Supervisor or Manager of Utilization/Case Management with a Managed Care Organization
+ 3 years in Behavioral Health
**LICENSES or CERTIFICATIONS**
+ United States Registered Nurse (RN) license
+ Delaware RN license must be obtained within the first 6 months of employment, unless the home state license is part of the compact
+ Compliance with all regulatory agency requirements is essential as consequences could result in potential for sanctions up to possible contract termination for all product lines
+ Complete other duties and projects as designated by the Utilization Management Director
+ General experience with computer skills (Microsoft Office/Outlook)
**Language (Other than English)**
0% - 25%
**PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS**
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
**_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.
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Req ID: J218301
- Behavioral Medicine
- Business Requirements
- Case Management
- Certified Nurse Practitioner
- Clinical Works