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Assist in the development and implementation of utilization management programs including but not limited to: prior authorization, dose and duration edits, quantity limits, step-care edits, generic sampling medical policy review and development, member facing outreach initiativesDevelop and implement physician, pharmacy, account, and member educational initiatives that promote the Organization's Formularies, utilization management programs, and disease management initiatives.
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The incumbent develops and implements physician, pharmacy, account, and member educational initiatives that promote the Organization’s Formularies, utilization management programs, and case/ disease management initiatives; providing clinical review and decisions for physician and member appeals and participates on cross-functional committees to develop and implement clinical and operational initiatives.
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Manage utilization review, translation of foreign claims, coordination of benefits (COB), and processing of claims with unique processing arrangements including Federal Employee Program (FEP) and Medicare Advantage.
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In addition to utilization review, the incumbent participates as the physician member of the multidisciplinary team for case and disease management. Conduct electronic review of escalated cases against medical policy criteria, which may include telephonic peer-to-peer discussions, to determine medical necessity and appropriateness.
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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. Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned.
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Highmark Health Medical Director, Medicaid (Remote PA, DE or WV) Providence, Rhode Island Apply Now. Participate in protocol and guidelines development to ensure consistency in the review process.
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Highmark Health - Medical Director, Medicaid (Remote PA, DE or WV) 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.
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At times, build cases in Utilization Review system during high volume times. 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.
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This job captures all inbound requests for utilization review from providers and pharmacies. The incumbent assesses the request, conducts all necessary research such as verifying benefit coverage for the patient, and then creates the case (data entry) in Highmark's utilization management system for clinical review.
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Implement care management review processes that are consistent with established industry, corporate, state, and federal law standards and are within the care manager’s professional discipline. Description : JOB SUMMARYThis job implements effective complimentary utilization and case management strategies for an assigned member panel.
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The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. Compose clear and concise rationales for member and provider determination notifications all while adhering to required compliance standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.
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Attend huddles and grand rounds. 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice) Depending on the nature of the case, telephonic peer to peer discussions may be required.
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Highmark Health Medical Director Bismarck, North Dakota Apply Now. 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.
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Highmark Health Medical Director Concord, New Hampshire Apply Now. Base 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.
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Highmark Health Medical Director Montgomery, Alabama Apply Now. Master's Degree in Business Administration/Management or Public Health. 1 year in Medical Management in a Health Insurance Plan; strong knowledge of managed care industry.
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utilization review jobs Company: Highmark Health in Windsor-mill, Maryland
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