Company :Highmark Inc.Job Description : 

JOB SUMMARY

This position will serve as the SME for a team that performs non-clinical quality audits and tasks in compliance with all regulatory guidelines. This role will support being an escalation point for the production team members, ensuring appropriate level of support to ensure compliance and timeliness. This role will assist the manager in monitoring the day to day functions of the production team including running reports to populate production metrics and identifying opportunities for additional training for team members. This role will be required to perform a certain level of production each month, as determined by the manager to ensure compliance with Desk Level Procedures (DLP) changes.  This role will be required to support production in any capacity if the inventory requires support. 

ESSENTIAL RESPONSIBILITIES

Serve as primary escalation point for all quality production team members, ensuring compliance and quality standards are met. This includes facilitating calibration sessions, maintaining proficiency test question repository, creating/updating quality documents/DLP's/SOP's, and continual process improvement.Assist the Manager in monitoring daily production of team members and identify team members that require additional training. Bring trends to the attention of the Supervisor. Complete special projects that would otherwise prevent full production quality audit staff from completing daily/monthly audit requirements for departmental staff. Projects may include but are not limited to privacy matters, state specific mandates, vendor operations, etc.Review quality rebuttals and remediate as necessary, collaborating with supervisory staff for their understanding of quality outcomes.Perform a certain level of production each month as determined by the manager.Other duties as assigned or requested.

EXPERIENCE

Required

5 years of progressive experience in claims support and processing, customer service, billing, enrollment, benefits administration, and/or utilization management 

Preferred

3 years of Healthcare Industry experience3 years of Working knowledge of medical procedures and terminology3 years of experience in Health Care claims, Health Insurance and Benefit Administration

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SKILLS

Possess good written and oral telephonic communication skillsAbility to navigate through multiple systems simultaneouslyKnowledge of administrative and clerical procedures and systems such as word processing, managing files, digital fax, and SharePointAbility to interact well with peers, supervisors, and customersProblem-SolvingKnowledge of principles and processes for providing customer service.  This includes customer needs assessment, meeting quality standards for servicesAbility to understand the implications of new information for both current and future problem-solving and decision-making.Ability to give full attention to what other people are saying, take time to understand the points being made, ask questions as appropriate, and not interrupt at inappropriate timesAbility to solve complex issues on multiple levels, and solve problems independently and creatively Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems

EDUCATION

Required

High School/GED

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Substitutions

None

LICENSES or CERTIFICATIONS

Required

None

Preferred

None

Language (Other than English):

None

Travel Required:

Less than 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based or Remote Position

Physical work site required

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 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:

$24.53

Pay Range Maximum:

$38.00

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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