PA Office Support Representative

Highmark Inc. Job Overview

Receive, review and make determinations regarding physician reviewer assignments for medical management decisions. Cases requiring physician review are provider and member requests, received from Medical Management & Policy (MM&P) and Member Grievance Departments.

Responsible for management of Peer to Peer telephone line. Will handle calls in accordance with regulatory requirements.

The timely assignment of cases in accordance with regulatory agencies' standards including the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Committee (URAC), Pennsylvania Department of Health, Department of Labor, the Center for Medicare and Medicaid Services (CMS) and state specific regulations.

Efficient communication and follow up with internal and external providers and contracted vendors.

Responsible for the timely receipt, review and assignment of all incoming physician reviewer referrals and appeals to ensure that NCQA, URAC, CMS, DOH, DOL and state specific regulatory compliance standards are met.

Responsible for the timely and efficient management of the physician peer to peer telephone line, including follow up with providers and provider office staffs to clarify and request information and provide follow up as necessary.

Responsible to efficiently coordinate the clinical review process with contracted external review companies in accordance with all regulatory guidelines.

Responsible for the timely sorting and filing of all required case information.

Responsible for data entry, maintenance and integrity of all databases.

Minimum : High School Diploma / GED, 3-5 years of related, progressive experience. Exempted experience requirements effective August 2016.

Ability to multi task and perform in a fast paced, and often intense environment.

Excellent written and verbal communication skills.

Be enthusiastic, innovative and flexible. Ability to make decisions that are consistently accurate.

Proficient in navigating through Highmark systems. Team player that possesses strong analytical and organizational skill.

The ability to prioritize work demands and meet deadlines.

Excellent computer and software knowledge and skills.

The incumbent must be able to function interact with all members of the health care team, both internal and external.

This incumbent requires the willingness and ability to report to work on a regular and timely basis and may require working irregular hours, holidays, and / or weekends.

Ability to analyze data, measure outcomes and develop action plans.