Highmark utilization management

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The incumbent is accountable for the oversight; development and maintenance of the department's care management processes. This includes utilization management, strategic planning, care cost initiatives, system development and quality outcomes.

Hires, trains, coaches, counsels, and evaluates performance of direct reports. Also responsible for appropriate application of medical policy and criteria. Works closely with claims, service, Provider Relations, HMS and other departments within the corporation to resolve issues and ensure activities coincide with Utilization Management processes.

Office-Based Positions The employee, either for an office or work from home arrangement, generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours, including weekends and nights to provide coverage. 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 position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. 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. This website uses cookies. It uses cookies to ensure that it gives you the best experience on our website.

If you continue without agreeing to the cookie conditions, we'll assume that you are happy to receive all cookies on this website. Read more. Covid Vaccination Information Effective November 1, , Highmark Health and its affiliates are requiring all new hires beginning employment to submit proof of full vaccination with one of the three authorized COVID vaccines. Role model to staff and assist in the day to day activities as needed. Provide service support, training and performance statistics to the team in addition to initiating and implementing process improvements.

Perform management functions including, but not limited to: recruitment, selection, orientation, performance measurement; counseling, and performance improvement planning; promotion and termination per corporate policy; and career development and support of staff.

Apply clinical knowledge to work with facilities and providers for care-coordination. Highmark will provide written notice when codes are added to the list; deletions are announced via online publication. Examples of services that may require authorization include the following. This is not an all-inclusive list. Benefits can vary; always confirm member coverage. The online portal is designed to facilitate the processing of authorization requests in a timely, efficient manner.

If you are a Highmark network provider and have not signed up for NaviNet, learn how to do so here. Highmark recently launched a utilization management tool, Predictal, that allows offices to submit, update, and inquire on medical inpatient authorization requests. Fax: If you are unable to use NaviNet, you may also fax your authorization requests to one of the following departments.

The associated preauthorization forms can be found here. Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number , which can be found here. Highmark contracts with WholeHealth Networks, Inc. Additional information about the programs and links to prior authorization codes are available under Care Management Programs in the left website menu.

Authorization number not appearing, unable to locate member, questions about clinical criteria screen. Contact Us. Provider Directory.

Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Quick Links: Manuals.

Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies.