Company :Highmark Inc.Job Description :JOB SUMMARYThis job performs accurate and timely processing of pre-certification requests for authorization of medically necessary health care services, at the appropriate level of care, based on the benefits for the line of business, and in compliance with the organization's policies, procedures and regulatory requirements. Documents, processes and routes requests for services to the nurse reviewer and other departments based on documentation procedures, including review type, clinical information, and decision timeframes. Follows policies and procedures to assure case completion and compliance with state and federal regulatory agencies. Maintains or exceeds department standards for call volume, response time and related production and quality measures. May interact with other departments and providers to resolve cases.ESSENTIAL RESPONSIBILITIES
Proactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are met.
Communicate effectively with Utilization Management Staff, providers, other internal and external customers and management.
Route Cases Based on Established Guidelines.
Provide accurate and timely routing of service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelines.
Process service requests meeting established guidelines, and document and route requests that are not permitted.
Request additional information verbally and in writing when the information provided is not adequate to make a medical necessity determination.
Escalate appropriate cases to leadership that require a clinical review and/or other intervention.
Assist with reporting as directed.
Participate in precepting of new employees, as assigned.
Maintain or exceed department call center standards.
Adhere to line of business phone standards to assure regulatory requirements are met.
Utilize phone functions to monitor the number of calls in queue and wait time.
Utilize daily phone standard reports to assess opportunities for self-improvement.
Meet or exceed standards for other production and quality measures.
Other duties as assigned or requested.
EXPERIENCERequired
3 years of experience in customer service
3 years of experience in typing, keyboard and computer skills
3 years of work experience in medical terminology
Preferred
Work experience with ICD-9 and/or CPT coding
Skills
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
EDUCATIONRequired
High School diploma / GED
Preferred
Associates degree or certification in a health related occupation
Language (Other than English):NoneTravel Requirement:0% - 25%PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition TypeOffice-basedTeaches / trains others regularlyOccasionallyTravel regularly from the office to various work sites or from site-to-siteRarelyWorks primarily out-of-the office selling products/services (sales employees)NeverPhysical work site requiredYesLifting: up to 10 poundsConstantlyLifting: 10 to 25 poundsOccasionallyLifting: 25 to 50 poundsRarelyDisclaimer: 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:$21.53Pay Range Maximum:$32.30Base 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.EEO is The LawEqual Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migratedfiles/employers/posterscreenreaderoptimized.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 contact HR Services Online at HRServices@highmarkhealth.orgCalifornia Consumer Privacy Act Employees, Contractors, and Applicants NoticeReq ID: J252815
