Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.
ADA
E1. Performs either pre or post service review for medical necessity utilizing criteria, medical policy and submitted medical information. Prepares any case that does not meet medical necessity to submit to a Medical Director. Post review, informs member, MD and/or facility of the decision in a written document and/or an oral response. May prepare various correspondences including Initial Adverse Determination, Final Adverse Determination, approval or a Last Covered Day within required time frame guidelines. Utilizes multi computer applications to effectively perform duties.
E2. 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.
E3. Utilizes and applies knowledge and understanding of CPT procedure codes, HCPC (DME) codes and ICD (Diagnosis) codes in performance of duties.
E4. Travel and communication with facilities and Provider community, in the course of duties, as necessary.
N5. Performs other related duties as required.

Education/Experience/Skills Requirements
Required Education: Required Experience:
Associates Degree: Nursing Bachelor’s Degree preferred. NYS RN license is required. Minimum three (3) years of clinical experience required.

Bachelor’s Degree: Nursing Or Masters degree Behavioral Health Specialist. 1-3 years Clinical and Managed Healthcare experience required. 3-5 years Behavioral Health and/or Substance Abuse experience required. NYS LMSW, LCSW, LMHC, or RN. CASAC or RN with Behavioral Health experience.

CCM (Certified Case Manager) preferred.

Required Knowledge/Skills:
1. Excellent time management skills with the ability to multitask and be flexible based on department needs
2. Public communication and presentation skills
3. Computer applications; including but not limited to: Microsoft Office applications
4. Excellent organizational skills and attention to detail
5. Excellent verbal and written communication skills
6. Strategic thinking/planning skills and ability to work effectively with minor supervision
7. Polished, professional image and reputation. Demonstrated personal accountability.
8. Must be able to work in a fast-paced team environment with daily work processing under highly regulated deadlines
9. High degree of business maturity and demonstrated confidentiality
10. Effective oral and written communication skills. Ability to prepare accurate and timely documentation.
11. For Behavioral Health candidates: Preferred experience in utilization management, managed care, health insurance industry, including an understanding of Behavioral Health provider specialties, Behavioral Health service delivery systems, and Behavioral Health levels of care
12. Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record) if applicable to the job responsibilities, i.e., on-site

Required Licenses/Certifications:
Registered Nurse OR Licensed Clinical Social Worker (LCSW) ORLicensed Mental Health Counselor (LMHC)

Problem Solving
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: UM tasks and actions require interaction with provider offices, facilities, vendors, member and external regulatory agencies.
Working Conditions/Physical Demands:
Position requires:
* Must be able to accommodate local travel. Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record)
* Irregular hours
* Must be able to accommodate alternate shifts/days
* Must be able to occasionally attend off-site meetings, events, conferences
* Must be able to work in an office environment
* Must have ability and access to work from remote location such as home
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)
* Physical Effort: Minimum; typical of most office work. Mostly sedentary work.
* Prolonged Sitting
* Reaching
* Repetitive Motion
* Vision Req: Close vision (clear vision at 20 inches or less)
* Vision Req: Distance (clear vision at 20 feet or more)
* Walking
* Weight: lift/carry/push/pull under 10 lbs.

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, 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, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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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