Spec Quality Improvement and Compliance

Company :

Highmark Inc.

Job Description : 

*********

Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.
ADA
E1. Responsible for performing pre or post service review for claim determination based upon medical policies. Prepares any case that does not meet medical necessity to submit to a Medical Doctor. Post review, informs members, groups or providers of the decision in a written document and/or an oral response. May prepare various correspondences including Second Level Adverse Determination and Final Adverse Determination within time frame guidelines.
E2. Education with claims and customer service supervisors and management to assure TPA claims processors are knowledgeable regarding current and new industry standards. Manages Large Claim Notifications and LCM reports from the Utilization Review Departments, as well as precert verification.***** Manages Third Party Liability/Subrogation cases. Business includes medical and transplant claims; Short Term Disability claims. Processing includes adjudication of disability claims, disability consulting and management of correspondence, internal and external ************
E3. Triages provider requests to comply with regulatory requirements: applies appropriate timeframes to meet regulatory requirements for requesting medical records or sending out the decisions. Maintains compliance with HIPAA (Health Insurance Portability and Accountability Act) for all work.
E4. ****Provides excellent communication and service with membership, clients, management, peers and other areas within the organization. Assists claims reps with questions on all aspects of claims processing. Reviews and responds to referrals (internal and external). Manages 2nd Level Appeals, IER’s, and RX Appeals. Maintains the IRO log. Staff training and development. Updates documentation and standard operating procedures.***********
E5.***** Responsible for handling and coordination of all Subrogation cases by working with attorney’s on recovery of lien. Maintains the subrogation log.
E6. Provide notification/disclosure to underwriting of potential high dollar claimants. Provides clinical updates to reinsurance carriers, account executives and underwriters during group renewal period.***************
Education/Experience/Skills Requirements
Required Education:
Associates Degree
Required Experience:
Minimum 5 years prior claims processing experience.
Required Knowledge/Skills:
1. Detailed knowledge of claims processing and ability to work in a fast paced production environment
2. Excellent communication skills both verbal and written
3. Must be detail oriented and possess strong organizational skills
4. Excellent problem solving and tactful skills when dealing with clients and coworkers
5. Ability to make sound decisions referencing all resources available
6. Ability to work with the team and promote teamwork
7. Must possess basic computer navigation skills and proficient in Microsoft Office (Word and Excel)
Required Licenses/Certifications:
Problem Solving
Ability to research and seek assistance through resources provided to ensure resolution on claim or correspondence is completed for cases assigned to the unit leader and for the workload assigned to the team.
Managerial/Supervisory Responsibilities
Does this Position have Supervisory Responsibility? No
Number of Emps Supervised:
Titles of Employees Supervised:
Financial/Budgetary Responsibilities:
Other Job Specifications:
External Contacts:
Working Conditions/Physical Demands:
Position requires:
* Must be able to work in an office environment
Position involves:
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
* Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)

Pay Range Minimum:

$20.80

Pay Range Maximum:

$37.43

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.  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. 

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