Highmark Health
Overview
Highmark Inc. Job Summary: This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate medical necessity and appropriateness of the requested treatment or service. Depending on the nature of the case, telephonic peer-to-peer discussions may be required. The incumbent ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management, advising the team on high-risk cases. The incumbent may be assigned special projects to help support and improve member care.
Responsibilities
Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determinations of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider notifications while adhering to compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations). Ensure that all aspects of the medical management process are consistent with community standards of care.
Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise the multidisciplinary team on cases that require physician expertise.
Participate in protocol and guidelines development to ensure consistency in the review process.
Actively manage projects and/or participate on project teams that require a physician subject matter expert.
Other duties as assigned.
Education
Required Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) Substitutions None Preferred Master\'s Degree in Business Administration/Management or Public Health
Experience
Required 5 years in clinical, direct patient care (hospital, outpatient, or private practice) Preferred 1 year in Medical Management in a health insurance plan; strong knowledge of the managed care industry
Licenses and Certification
Required Medical Doctor or Doctor of Osteopathic Medicine (DO) Awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards Active medical state licensure required. Additional state licensure(s) may be required based on business need. Preferred None
Skills
Critical Thinking Case Management Customer Service Oral and Written Communication Skills Collaboration Listening Telephone Skills General Computer Skills Clinical Software Managed Care
Language
None
Travel
0% - 25%
Physical, Mental Demands, and Working Conditions
Position Type: Office-Based Teaches / trains others regularly: Occasionally Travel regularly from the office to various work sites or site-to-site: Rarely Works primarily out of the office selling products/services: Rarely Physical work site required: No Lifting: up to 10 pounds: Constant Lifting: 10 to 25 pounds: Rarely Lifting: 25 to 50 pounds: Rarely
Disclaimers and Compliance
The job description is intended 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 to do this job. This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. Employees may have access to confidential information and must comply with HIPAA and data security policies. Employees must comply with the company\'s Code of Business Conduct and applicable laws, rules, and regulations.
Pay
Pay Range Minimum: $170,000.00 Pay Range Maximum: $342,274.00 Base pay is determined by qualifications, experience, and other factors. The salary range may be adjusted for geographic differences.
Highmark Health and its affiliates are equal opportunity employers. EEO statements and accessibility information are provided as required by law.
Req ID: J254551
#J-18808-Ljbffr
Highmark Inc. Job Summary: This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate medical necessity and appropriateness of the requested treatment or service. Depending on the nature of the case, telephonic peer-to-peer discussions may be required. The incumbent ensures compliance with NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management, advising the team on high-risk cases. The incumbent may be assigned special projects to help support and improve member care.
Responsibilities
Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determinations of cases, review of appeals and grievances, and other reviews as assigned. Compose clear and concise rationales for member and provider notifications while adhering to compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations). Ensure that all aspects of the medical management process are consistent with community standards of care.
Participate as a member of the CMDM multidisciplinary team. Attend huddles and grand rounds. Advise the multidisciplinary team on cases that require physician expertise.
Participate in protocol and guidelines development to ensure consistency in the review process.
Actively manage projects and/or participate on project teams that require a physician subject matter expert.
Other duties as assigned.
Education
Required Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) Substitutions None Preferred Master\'s Degree in Business Administration/Management or Public Health
Experience
Required 5 years in clinical, direct patient care (hospital, outpatient, or private practice) Preferred 1 year in Medical Management in a health insurance plan; strong knowledge of the managed care industry
Licenses and Certification
Required Medical Doctor or Doctor of Osteopathic Medicine (DO) Awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards Active medical state licensure required. Additional state licensure(s) may be required based on business need. Preferred None
Skills
Critical Thinking Case Management Customer Service Oral and Written Communication Skills Collaboration Listening Telephone Skills General Computer Skills Clinical Software Managed Care
Language
None
Travel
0% - 25%
Physical, Mental Demands, and Working Conditions
Position Type: Office-Based Teaches / trains others regularly: Occasionally Travel regularly from the office to various work sites or site-to-site: Rarely Works primarily out of the office selling products/services: Rarely Physical work site required: No Lifting: up to 10 pounds: Constant Lifting: 10 to 25 pounds: Rarely Lifting: 25 to 50 pounds: Rarely
Disclaimers and Compliance
The job description is intended 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 to do this job. This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. Employees may have access to confidential information and must comply with HIPAA and data security policies. Employees must comply with the company\'s Code of Business Conduct and applicable laws, rules, and regulations.
Pay
Pay Range Minimum: $170,000.00 Pay Range Maximum: $342,274.00 Base pay is determined by qualifications, experience, and other factors. The salary range may be adjusted for geographic differences.
Highmark Health and its affiliates are equal opportunity employers. EEO statements and accessibility information are provided as required by law.
Req ID: J254551
#J-18808-Ljbffr