PA Office Support Representative
Listed on 2026-01-31
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Healthcare
Healthcare Administration, Medical Records
Company :Highmark Inc.
Job Description : GENERAL 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.
ESSENTIAL RESPONSIBILITIES- The timely, accurate assignment of requests to internal physician reviewers/medical directors
- The timely, accurate entry of requests into the database for reporting purposes (20%)
- The submission and receipt of clinical information
- Effective communication with the external review liaison to address questions or
- The efficient and accurate recording of all case information submitted for external review (20%)
Minimum
- High School Diploma / GED
- 3-5 years of related, progressive experience. Exempted experience requirements effective August 2016.
Preferred
- Experience in navigating managed care system
- Certification or equivalent training in Word Processing, Database Management or Medical Terminology
Knowledge,
Skills and Abilities
- 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.
Scope of Responsibility:
Does this role supervise/manage other employees? No
Work Environment:
Is Travel Required? No
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…
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