Highmark Health
This job works directly with network providers to support key clinical transformation programs with a focus on utilization of appropriate care. The team member works with internal and external stakeholders to ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. The team member will also work with providers to identify specific areas of improvement within the same domain and help providers develop meaningful action plans to improve performance. The team member is responsible for building relationships, engaging clinicians, educating on Utilization Management policies and processes, developing workflows and resources, and improving provider performance.
Required: 5 years experience in any of the following healthcare areas:the provider environment (hospital, facility, PCP, specialist, supporting area(s)), or healthcare insurance industry, or healthcare administration in a provider office, hospital and/or health systems, or healthcare consulting in provider setting. 3 years of experience in utilization management/care management/QA/managed care Preferred: 3 years of experience in data analysis, interpretation, and outcomes strategic plan development. 1 year of lean, six sigma, TQI, TQC or other quality and/or project management certification SKILLS: Ability to analyze data, measure outcomes, and develop action plans Working knowledge of pertinent regulatory and compliance guidelines and medical policies Ability to multitask and perform in a fast-paced and often intense environment that requires flexibility Excellent written and verbal presentation skills, excellent interpersonal and negotiation skills, and ability to positively influence others.Engages with external stakeholders with a professional demeanor and customer-centered mindset. Be a team player who possesses strong analytical and organizational skills. EDUCATION Required: Bachelorās degree in nursing OR licensed RN with associate's degree or RN diploma. Preferred: None LICENSES or CERTIFICATIONS Required: Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Preferred: PA Driver's license Certification in nursing area of expertise
Review provider performance according to accepted and established criteria, as well as other approved guidelines and medical policies. Analyze qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Educate providers and other relevant external stakeholders on medical policy clinical criteria used to authorize care on a proactive basis. Develop and sustain positive working relationships with internal and external customers. Respond to customer inquiries and offers interventions and/or alternatives. Other duties as assigned or requested.
Basic
Telehealth
$34
Resume Template Package
ATS optimized design for nurses
Matching Cover Letter
Matching Reference Page
Resume Tips and Tricks
ADVANCED
Telehealth
$79
Everything from Starter Pack
Resume Optimization Guide
7 Nurse Resume Examples
20+ Professional Summary Examples
How to Structure Unique Career Experiences
BEST VALUE
Telehealth
$149
Everything from Starter Pack
Everything from Pro Toolkit
Career Accelerator Success Guide
Proven method for landing your dream role
Lifetime Premium Job Board Access
Application Tracker
1:1 Expert Support