Home, Michigan

**Company :**

Highmark Inc.

**Job Description :**

**JOB SUMMARY**

This job leads and directs the organization's prior authorization processes and functions relative to outpatient procedures, durable medical equipment (DME), home health, and planned acute-care inpatient admissions. This includes leading/managing three teams of nurses including the Medicare Advantage team, the commercial special groups team, and the commercial other team, in addition to the non-clinical intake staff and the administrative support staff. This job requires expertise in the areas of utilization management, benefit interpretation, insurance industry regulations/compliance standards and personnel management. The leader is accountable for the operational excellence of the prior authorization unit, control of administrative costs, care cost initiatives, system development, delivery of high-quality outcomes, compliance with all state and federal regulations that affect utilization management (UM) activities and any needed reporting in a complete and timely manner. The leader is ultimately responsible for compliance with NCQA, URAC, CMS, DOH and DOL regulations as related to utilization management activities and for ensuring an exceptional customer experience that facilitates appropriate resource utilization in the most appropriate care setting.

**ESSENTIAL RESPONSIBILITIES**

+ Performs management responsibilities including, but not limited to: hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity management.

+ Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.

+ Ensures uniform core competencies among utilization management staff through ongoing training, education, inter-rater reliability testing, and performance monitoring, including a continual focus on the correct, efficient and thorough application of inter-mural criteria and/or Milliman Care Guidelines (as applicable) and utilization of applicable software applications/tools to the fullest extent possible.

+ Performs strategic planning for the department; accountable for the operational excellence of the unit, control of administrative and care cost initiatives, system development and delivery of high-quality outcomes, compliance with all state and federal regulations that affect utilization management activities and any needed reporting in a complete and timely manner.

+ Develops and periodically evaluates administrative policies and procedures for the area and reviews the policies and procedures at least on an annual basis. Ensures that utilization management requests are handled at the most appropriate staff level.

+ Monitors, reports and controls departmental activities to optimize efficiency and effectiveness and improve outcomes for members.

+ Maintains current knowledge of applicable CMS, state, local, and regulatory agency requirements and standards related to utilization management/utilization review or other areas of responsibility.

+ Other duties as assigned or requested.

**EDUCATION**

**Required**

+ Bachelor's Degree in Nursing

**Substitutions**

+ 6 years of relevant experience in Nursing to include an RN license

**Preferred**

+ Bachelor’s Degree in Business or Healthcare related field

**EXPERIENCE**

**Required**

+ 7 years of experience in Nursing, Healthcare Industry or other related field

To Include

+ 5 years of experience in management and/or leading teams

+ 5 years of experience in utilization management or utilization review

**Preferred**

+ Certification in case management or utilization management

+ Prior clinical experience in a variety of settings including a mixture of provider-based and payer-based positions

**LICENSES or CERTIFICATIONS**

**Required**

+ Registered Nurse

**Preferred**

+ None

**SKILLS**

+ Strategic thinking skills

+ Excellent written and verbal communication skills

+ Extensive knowledge of utilization management/utilization review in a payer-based or health plan environment

+ Ability to analyze data, measure outcomes and develop and implement action plans

+ Computer literacy and knowledge of utilization management software applications and basic office applications such as Excel, Word, PowerPoint, etc.

+ Demonstrated proficiency in customer service skills and highly effective interpersonal skills

+ Demonstrated effective leadership and managerial skills

+ Demonstrated ability to be a change agent

**Language (Other than English):**

None

**Travel Requirement:**

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 from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

**_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._

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.

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 Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( _https://www.eeoc.gov/sites/default/files/migrated\_files/employers/poster\_screen\_reader\_optimized.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.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Req ID: J190366

Home, Michigan

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