Qureos Mentor

Highmark Health

<div><h2 class="jobSectionHeader">Company :
</h2>Highmark Inc.
<h2 class="jobSectionHeader">Job Description :
</h2>JOB SUMMARY
This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.
ESSENTIAL RESPONSIBILITIES
<ul><li>Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager&rsquo;s professional discipline.
</li><li>Function in accordance with applicable state, federal laws and regulatory compliance.
</li><li>Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
</li><li>Promote quality and efficiency in the delivery of care management services.
</li><li>Respect the member&rsquo;s right to privacy, sharing only information relevant to the member&rsquo;s care and within the framework of applicable laws.
</li><li>Practice within the scope of ethical principles.
</li><li>Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
</li><li>Employ collaborative interventions which focus, facilitate, and maximize the member&rsquo;s health care outcomes. Is familiar with the various care options and provider resources available to the member.
</li><li>Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
</li><li>Develop and sustain positive working relationships with internal and external customers.
</li><li>Utilize outcomes data to improve ongoing care management services.
</li><li>Other duties as assigned or requested
</li></ul>EDUCATION
Required
<ul><li>None
</li></ul>Substitutions
<ul><li>None
</li></ul>Preferred
<ul><li>Bachelor&rsquo;s Degree in Nursing
</li></ul>EXPERIENCE
Required
<ul><li>3 years of related, progressive clinical experience in the area of specialization
</li><li>Experience in a clinical setting
</li></ul>Preferred
<ul><li>Experience in UM/CM/QA/Managed Care
</li></ul>LICENSES AND CERTIFICATIONS
Required
<ul><li>Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Additional specific state licensure(s) may be required depending on where clinical care is being provided.
</li></ul>Preferred
<ul><li>Certification in utilization management or a related field
</li></ul>SKILLS
<ul><li>Working knowledge of pertinent regulatory and compliance guidelines and medical policies
</li><li>Ability to multi task and perform in a fast paced and often intense environment
</li><li>Excellent written and verbal communication skills
</li><li>Ability to analyze data, measure outcomes, and develop action plans
</li><li>Be enthusiastic, innovative, and flexible
</li><li>Be a team player who possesses strong analytical and organizational skills
</li><li>Demonstrated ability to prioritize work demands and meet deadlines
</li><li>Excellent computer and software knowledge and skills
</li></ul>Languages (Other than English)
None 
 
Travel Requirement
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-Based
Teaches/trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Does Not Apply
Works primarily out-of-the office selling products/services (sales employees)
Does Not Apply
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely, Occasionally
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.
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&rsquo;s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee&rsquo;s responsibility to comply with the company&rsquo;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:
$68,400.00
Pay Range Maximum:
$105,900.00
Base pay is determined by a variety of factors including a candidate&rsquo;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.
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 the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice</div>

Care Manager RN (Remote)

<div><h2 class="jobSectionHeader">Company :
</h2>Highmark Inc.
<h2 class="jobSectionHeader">Job Description :
</h2>JOB SUMMARY
This job is responsible for completing all Prior Authorization outbound call tasks and/or inbound triage case creations. In compliance with regulatory guidelines (e.g., NCQA, CMS), the incumbent informs the member and/or provider of the approval and/or denial of the requested authorization.
 
 
ESSENTIAL RESPONSIBILITIES
<ul><li>Obtain call task from Utilization Management platform, perform verbal outbound call task requirement following a detailed script and desk level procedure, and appropriately log result within the platform.
</li><li>Obtain triage task from Utilization Management platform and follow a detailed desk level procedure to enter the required fields to set up the case build (data entry) and set the urgency of the case creation for the Intake Coordinator.
</li><li>Other duties as assigned or requested.
</li></ul>EXPERIENCE 
 
Required
<ul><li>1 year of Healthcare experience
</li><li>1 year of Customer Service experience
</li></ul>Preferred
<ul><li>1 year of Call Center experience 
</li></ul> 
SKILLS
<ul><li>Possess good written and oral telephonic communication skills
</li><li>Ability to navigate through multiple systems simultaneously
</li><li>Knowledge of administrative and clerical procedures and systems such as word processing, managing files and digital fax
</li><li>Ability to interact well with peers, supervisors, and customers 
</li></ul> 
EDUCATION 
 
Required
<ul><li>High School Diploma 
</li></ul> 
Preferred
<ul><li>None 
</li></ul> 
LICENSES or CERTIFICATIONS 
 
Required
<ul><li>None 
</li></ul> 
Preferred
<ul><li>None 
</li></ul> 
Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office- or Remote-based
Physical work site required
Constantly
Travel Required
0% - 25%
Audible Speech
Frequently
Hear
Frequently
Position self or move lower on ground, under tables/desk, etc.
Occasionally
Climb
Occasionally
Drive
Never
Reach
Occasionally
Sedentary Position
Constantly
Move
Occasionally
Repetitive Motion
Constantly
Use Hands/Fingers to Handle or Feel (beyond data entry)
Occasionally
Vision - Distinguish Color
Occasionally
Vision - Far, near, Depth Perception
Occasionally
Lifting: up to 10 pounds
Constantly
Lifting: up to 20 pounds
Occasionally
Lifting: up to 50 pounds
Never
Lifting in excess of 50 pounds
Never
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&rsquo;s Handbook of Privacy Policies and Practices and Information Security Policy.
 
 
Furthermore, it is every employee&rsquo;s responsibility to comply with the company&rsquo;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:
$19.39
Pay Range Maximum:
$24.19
Base pay is determined by a variety of factors including a candidate&rsquo;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.
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 the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice</div>

Associate Intake Coordinator

<div><h2 class="jobSectionHeader">Company :
</h2>Highmark Inc.
<h2 class="jobSectionHeader">Job Description :
</h2>JOB SUMMARY
This job is responsible for completing all Prior Authorization outbound call tasks and/or inbound triage case creations. In compliance with regulatory guidelines (e.g., NCQA, CMS), the incumbent informs the member and/or provider of the approval and/or denial of the requested authorization.
 
 
ESSENTIAL RESPONSIBILITIES
<ul><li>Obtain call task from Utilization Management platform, perform verbal outbound call task requirement following a detailed script and desk level procedure, and appropriately log result within the platform.
</li><li>Obtain triage task from Utilization Management platform and follow a detailed desk level procedure to enter the required fields to set up the case build (data entry) and set the urgency of the case creation for the Intake Coordinator.
</li><li>Other duties as assigned or requested.
</li></ul>EXPERIENCE 
 
Required
<ul><li>None
</li></ul>Preferred
<ul><li>1 year of Customer Service experience
</li><li>1 year of Call Center experience
</li>1 year of Healthcare experience 
<li>
</li></ul> 
SKILLS
<ul><li>Possess good written and oral telephonic communication skills
</li><li>Ability to navigate through multiple systems simultaneously
</li><li>Knowledge of administrative and clerical procedures and systems such as word processing, managing files and digital fax
</li>Ability to interact well with peers, supervisors, and customers 
<li>
</li></ul> 
EDUCATION 
 
Required
High School Diploma 
<ul><li>
</li></ul> 
Preferred
None 
<ul><li>
</li></ul> 
LICENSES or CERTIFICATIONS 
 
Required
None 
<ul><li>
</li></ul> 
Preferred
None 
<ul><li>
</li></ul> 
Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office- or Remote-based
Physical work site required
Constantly
Travel Required
0% - 25%
Audible Speech
Frequently
Hear
Frequently
Position self or move lower on ground, under tables/desk, etc.
Occasionally
Climb
Occasionally
Drive
Never
Reach
Occasionally
Sedentary Position
Constantly
Move
Occasionally
Repetitive Motion
Constantly
Use Hands/Fingers to Handle or Feel (beyond data entry)
Occasionally
Vision - Distinguish Color
Occasionally
Vision - Far, near, Depth Perception
Occasionally
Lifting: up to 10 pounds
Constantly
Lifting: up to 20 pounds
Occasionally
Lifting: up to 50 pounds
Never
Lifting in excess of 50 pounds
Never
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&rsquo;s Handbook of Privacy Policies and Practices and Information Security Policy.
 
 
Furthermore, it is every employee&rsquo;s responsibility to comply with the company&rsquo;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:
$19.39
Pay Range Maximum:
$24.19
Base pay is determined by a variety of factors including a candidate&rsquo;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.
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 the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice</div>

Join Highmark Health and explore 3   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Highmark Health

About Company

Care Manager RN (Remote)

Associate Intake Coordinator

Associate Intake Coordinator