Remote Utilization Review Rn Jobs in York, PA (NOW HIRING)

JOB SUMMARY

This job supports the acquisition of new accounts and retention of existing accounts by working directly with client managers within national and regional markets. The incumbent is primarily accountable for the delivery of clinical analysis and strategies for Highmark customers, including healthcare consultants and brokers. Provides and interprets client specific clinical data to facilitate the sale and implementation of optimal clinical interventions that deliver clinical and financial results. The incumbent is also expected to stay current on market trends, understand the competition, and assist the product, clinical, and analytic internal partners to execute on strategy. Represents the Organization as the subject matter expert for all clinical programs, products and recommendations to clients. Will assist with team development through mentoring, training and education.

ESSENTIAL RESPONSIBILITIES

• Perform as the clinical subject matter expert for clinical, quality, care, utilization, high-cost claim and population health management as part of the clinical presentations with external clients, brokers/producers and new to blue prospects.

• Develop strategy to support acquisition and renewal of membership; prepare for and provide clinical perspective on clinically-related discussions as needed; provide clinical and operational insights back to internal stakeholders and accounts after customer discussions. Participate in ad-hoc and annual clinical review meetings as needed to provide clinical, health and wellness perspective; provides broad clinical insights back to internal stakeholders and accounts after customer discussion.

• Develop and manage positive and effective relationships with key internal and external partners and decision makers including sales, product, provider, quality, clinical, pharmacy, partner plans, consulting firms, and third-party vendors. Keep pace with fast-changing environment, client cultures and trends to better support behavior change by increasing senior level support, improving value proposition with a goal of focused interventions, creative strategies and execution of all core clinical principles and programs.

• Collaborate with Clinical Strategy Analysts to create a message and deliver relevant metrics and clinical reports as well as quarterly and annual outcomes and trends for all clinical strategies for all current and emerging care models. Articulate the 'so what' to the customer by alignment of analytics and performance metrics to track quantitative clinical and financial results, and communicating value and progress for clients which contributes to sales and retention.

• In coordination with Sales, strategize to develop and implement data-driven, clinical intervention plans and strategies for the Organization's clients to effectively impact behavior change, risk, medical costs and productivity impairment.

• Research and stay current on health, wellness, productivity, risk and care management trends in the market place to share insights and best practices in sales discussions; attend conferences and contribute to publications as needed to support the clients, consultants, partners and centers of excellence function.

• Coordinate all post sale and ongoing aspects of clinical product implementation and outcomes with senior level executives at the client level, external vendors and brokers. Track, communicate and implement best practices and industry specific successes and challenges for all markets.

• Participate in departmental strategic planning, goal setting and strategic initiative coordination and lead the portion associated with the Clinical Strategy Consultants. Responsible for identifying and completing a process improvement project at least annually in conjunction with Clinical Strategy leadership team.

• Primary client contact for clinical related issues/questions. Participate in internal groups as needed, as a subject matter expert. Assist by providing appropriate content and consultation to support the RFP / RFI process.

• Other duties as assigned or requested.

EDUCATION
Required

• Bachelor's Degree in Nursing, Pharmacy, Physician Assistant or a clinical field

Substitutions

• None

Preferred

• Master's Degree in Business or a clinical field

EXPERIENCE
Required

• 5 years in a Clinical or Managed care setting

Preferred

• 3 years of Client Sales Support

• 3 years of external client facing

LICENSES or CERTIFICATIONS
Required (any of the following)

• Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

• Physician Assistant License

• Pharmacist (PharmD)

Preferred

• None

SKILLS

• Critical thinking skills

• Understanding of key clinical concepts

• Effective problem solving and decision-making skills

• Excellent interpersonal, presentation, communication and listening skills

• Strong business acumen

• Demonstrated effective presentation delivery

• Conflict and crisis management skills

Language (Other than English):

None

Travel Requirement:

25% - 50%

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

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 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'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.

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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