Company :Highmark Inc.Job Description : 

JOB SUMMARY 

This job is responsible for working with HHO clinical departments in the areas of compliance and process improvement. Serves as a corporate resource regarding accreditation standards, clinical performance and continuous improvement principles. Manages the oversight and development of clinical submissions for regulator inquiries. Oversees development and maintenance of Care Management policies and procedures to ensure accreditation and compliance with NCQA and DMMA requirements.  Monitors regulatory changes, industry trends, and contract changes on an ongoing basis. Conducts analysis and oversight of design, development, modification, adaptation, implementation and execution of solutions for improvement of short-term and long-term clinical and operational excellence. Collaborates with various organizational leaders to prepare briefings or reports and conduct data analyses.

 
ESSENTIAL RESPONSIBILITIES 

Serve as an internal project lead to ensure alignment and consistency in the organization's contractual clinical performance measurement across Care Management.  Manage and coordinate department activities including but not limited to: policy and procedure development and revision, individual staff audits, and overall operations to ensure compliance to standards and regulations. Serve as the point of contact and Highmark Health Options clinical representative to state regulators.Continuously examine processes and procedures to identify opportunities for improvement and refinement.Perform internal clinical audits for the purpose of quality assurance, and to assure compliance with respect to regulatory requirements and corporate policies/procedures.Recommend and develop corrective action plans to management. Oversee final plan implementation and communication.Effectively communicate outcomes, data analysis, complex processes and action plans to division/unit staff, corporate partners across departments and external customers.Research federal and state regulations and other regulatory materials, various business requirement contracts and subcontracted delegate entity to ensure compliance.Coordinate department accreditation, oversight and compliance activities with regulatory guidelines/agencies, including but not limited to NCQA and DMMA.Other duties as assigned or requested.

EXPERIENCE 

Required 

5 years of experience as working in a clinical setting.3 years of experience as case management/managed care (with specific knowledge of quality monitoring, compliance and/or regulatory processes)1 year of experience in evaluating, implementing or revising work processes

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 Preferred 

3 years of experience in performing auditing/monitoring functions.3 years of experience in creating tools, training documents and educational materials geared to adult learners.3 years of experience in healthcare/health insurance industry.

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SKILLS 

Workforce development and resource management with excellent team building and professional development skillsStrong leadership, collaboration, and motivational skillsStaff/project managementAbility to relate to all levels of management and staff as well as individuals external to the corporationAbility to multi task and perform in a fast paced, and often intense environmentExcellent written and verbal communication skillsAbility to analyze data, measure outcomes and develop action plansBe enthusiastic, innovative and flexible.Ability to prioritize work demands and meet deadlinesExcellent computer and software knowledge and skills

EDUCATION 

Preferred 

Bachelor’s degree in business, health care administration, nursing, or other related program.

LICENSES or CERTIFICATIONS 

Required 

RN, LCSW, LSW, LPC or related clinical licensure, Within 45 days of hire.

Preferred 

None 

 
Language (Other than English): 

None 

Travel Requirement: 

0% - 25% 

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS 

Position Type 

Office- or Remote-based 

Teaches / trains others 

Occasionally 

Travel 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 

No 

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.  

Pay Range Minimum:

$67,500.00

Pay Range Maximum:

$126,000.00

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 any category protected by applicable federal, state, or local law.

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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