Highmark · 1 day ago
PA Office Support Representative
Buffalo-Niagara Area
Full-time
Onsite
Mid Level
$20.31/hr - $30.12/hr
3+ years expHighmark Inc. is a healthcare company that is seeking a PA Office Support Representative. The role involves managing physician reviewer assignments for medical management decisions and ensuring compliance with various regulatory standards.
Health CareHealth InsuranceInsuranceWellness
Responsibilities
Receive, review and make determinations regarding physician reviewer assignments for medical management decisions
Responsible for management of Peer to Peer telephone line
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
Responsible for the timely receipt, review and assignment of all incoming physician reviewer referrals and appeals to ensure that NCQA, URAC, CMS, DOH, DOL and state specific regulatory compliance standards are met
Responsible for the timely and efficient management of the physician peer to peer telephone line, including follow up with providers and provider office staffs to clarify and request information and provide follow up as necessary
The management of the peer to peer telephone lines includes the timely, accurate assignment of requests to internal physician reviewers/medical directors
The timely, accurate entry of requests into the database for reporting purposes
Responsible to efficiently coordinate the clinical review process with contracted external review companies in accordance with all regulatory guidelines
This includes the submission and receipt of clinical information
Effective communication with the external review liaison to address questions or issues
The efficient and accurate recording of all case information submitted for external review
Responsible for the timely sorting and filing of all required case information
Responsible for data entry, maintenance and integrity of all databases
Other duties as assigned or requested
Qualification
Required
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
Additional relevant education level and/or years of experience
Company
Highmark
Highmark provides health insurance plans for individuals and businesses.
10001+ employees
Funding
Current Stage
Late StageTotal Funding
$27.3M2018-04-06Grant· $25M
2014-08-07Grant· $2.3M
Leadership Team
Deborah Rice-Johnson
CEO, Diversified Businesses at Highmark Inc. and Chief Growth Officer
Paul Sikora
CTO Provider Services
Recent News
2025-12-11
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