Highmark Health

Claims Specialist

• Screen, review, evaluate online entries, correct errors, and perform quality control review and final adjudication of paper/electronic claims
• Determine whether to return, deny, or pay claims according to organizational policies and procedures
• Review processed claims and inquiries to determine corrective action, including adjusting claims as necessary
• Use enrollment, benefit, and historical claim processing information to take corrective action
• Coordinate benefits and interact with customers as needed
• Complete claims adjustments resulting from audits, member/provider calls, other insurance information, appeals, and system changes
• Provide technical assistance in researching and resolving inquiries
• Receive and process claims by entering and verifying claims data
• Resolve claim edits, review history records, determine benefit eligibility, and determine final payment levels
• Escalate issues to supervision and maintain professional communication with internal and external customers
• Meet production and quality standards while maintaining timely and accurate work
• Maintain accurate records, including timekeeping records, and attend required training classes

Claims Processor

Manager

• Oversee external vendors and take responsibility for work quality
• Plan, manage, and oversee operational support of vendor relationships
• Work with client relationship teams and vendors to ensure contractual and SLA performance expectations are met
• Manage day-to-day operational issues and respond to high-priority, complex, or escalated vendor requests
• Recommend business process improvements based on technical problems, solutions, and business needs
• Represent and champion operational needs within vendor governance processes
• Escalate issues to the lead when necessary
• Coach and develop peers and vendor staff
• Manage vendor performance and productivity
• Monitor vendor contracts and partner with procurement on contract development and renewals
• Document vendor compliance with contract terms and requirements
• Ensure invoice accuracy, payments, contractual compliance, and delivery of desired vendor services
• Manage budgets, purchase orders, budget-system data, and monthly actual-versus-budget reporting to leadership
• Assist in developing vendor strategy and operationalizing the approach
• Lead creation and modification of the company-vendor operating model
• Perform other responsibilities as required

Senior Vendor Performance Manager

Clinician

• Provide comprehensive evaluation and treatment of acute psychiatric patients
• Provide individual, group, and family therapy with assigned patients
• Conduct comprehensive evaluations for assigned patients
• Complete documentation according to regulatory requirements, including treatment plans and progress notes
• Attend required departmental and hospital meetings
• Perform other duties as assigned or required
• Comply with HIPAA, data security guidelines, the Code of Business Conduct, applicable laws, regulations, company policies, and training requirements

Behavioral Health Clinician

Accounting Manager

• Lead all operational cost accounting activities for the Network under the Director, Cost Accounting
• Manage hiring and termination decisions, coaching and development, rewards and recognition, performance management, and staff productivity
• Plan, organize, staff, direct, and control day-to-day department operations
• Develop and implement policies and programs; manage budgetary responsibility and authority as applicable
• Establish consistent cost accounting principles across network entities
• Maintain cost type definitions, indirect cost allocation methodologies, direct cost assignments, cost center hierarchies, and related identifiers
• Direct cost analysts in maintaining cost allocation rules and processes for patient care cost information
• Use SAS, Excel, Tableau, Alteryx, and related decision-support tools to produce reports, analyses, recommendations, and interactive visualizations
• Diagnose financial health of clinical delivery methods and settings
• Enable institute-level financial reporting based on primary diagnosis data
• Inform payer reimbursement discussions
• Develop business cases for long-term operating strategies
• Prioritize capital equipment purchases and real estate development projects
• Develop and empower the team through mentoring and coaching
• Build collaborative relationships with hospital leaders and clinical teams to develop cost and productivity metrics
• Lead discussions translating clinical activity into productivity metrics using analytical tools, site visits, and video communications
• Provide training and assistance to departments using cost data and reporting tools
• Maintain data credibility through standards, data processing, audits, and reconciliations
• Perform other duties as assigned

Cost Accounting Manager

Physician Assistant

• Facilitate diagnostic and emergency care for patients in outpatient and acute inpatient settings
• Order and interpret laboratory, advanced radiological, and specialized diagnostic studies
• Institute emergency measures and stabilization techniques for acute patient situations
• Prepare and electronically prescribe medications; administer medications and injections
• Perform minor bedside surgical procedures and complex specialty-specific procedures
• Coordinate complex care with patients, families, community services, and interdisciplinary teams
• Initiate consultations for cases exceeding PA-C scope or requiring higher-level medical decision-making
• Provide specialized critical care and inpatient care
• Maintain accurate, complete, and timely medical record documentation
• Educate patients and families on health prevention, medications, and treatment instructions
• Ensure continuity of care across outpatient visits, inpatient admissions, and post-discharge follow-up
• Conduct daily inpatient hospital rounds and triage clinic calls and inquiries
• Participate in mandatory continuing education and quality improvement initiatives
• Assist with surgical, interventional radiology, and fluoroscopic procedures under supervision
• Contribute to education of trainees and professional staff
• Perform other assigned specialty-specific duties

Physician Assistant – Cardiology

Director

• Centralize and standardize nursing staff education throughout Allegheny Health Network and/or the outpatient setting
• Establish a system-wide educational plan aligned with the organization’s strategic mission
• Develop an educational framework for excellence in staff education and professional practice
• Establish an educational model and process reflecting best practices and ensuring regulatory compliance
• Organize and implement a centralized nursing education department for all nursing team members
• Select, direct, evaluate, recommend, and implement approved disciplinary action
• Plan, manage, and oversee initiatives creating a culture of professional excellence and high-quality care
• Lead teams and drive cultural change incorporating systems thinking and a team approach
• Incorporate health information technology into nursing education and use quality dashboards to manage and plan educational activities
• Create a certified centralized staff education team focused on shared decision-making
• Communicate with interprofessional teams and organize and plan meetings and conferences

Director of Nursing Education

Business Analyst

• Support analytical aspects of the application product life cycle and capability enablement within a product scope
• Collaborate with customers on complex issues to understand capability needs
• Gather project specifications and create business cases and cost sheet analyses
• Translate high-level business needs into detailed requirements for new capabilities and enhancements
• Analyze data to identify business problems, trends, and process improvement opportunities
• Create and execute test cases
• Provide root cause analyses and corrective action plans
• Verify delivery of customer needs and ensure quality delivery
• Identify, document, and resolve risks, defects, and issues
• Analyze market trends for competitive insights and business value statements
• Mentor Associate and Intermediate Business Systems Analysts
• Lead project teams or serve as a subject matter expert on moderately complex, cross-functional projects
• Act as the customer-facing representative and resolve complex, potentially multi-system issues
• Administer Planview Portfolios, including users, groups, roles, security, access, screens, menus, objects, attributes, reference tables, organizational and financial structures, resources, and portfolio hierarchies
• Configure and support workflows, lifecycle management, scripted dialogs, automation, approvals, governance checkpoints, and demand/project intake processes
• Develop and maintain Planview reports, executive dashboards, operational dashboards, governance dashboards, and portfolio health, resource utilization, financial management, and data quality reporting
• Support data governance, platform cleanup, configuration standards, reference data, taxonomy, audit reviews, and compliance reporting
• Support Planview Enterprise Architecture, AgilePlace, and ProjectPlace environments
• Support Planview integrations and troubleshoot data mappings, APIs, synchronization, monitoring, and errors
• Manage development, test, and production environments, configuration migrations, release planning, regression testing, quarterly release assessments, impact assessments, promotion governance, and release documentation
• Participate in governance boards, Change Advisory Boards, enhancement intake, prioritization, roadmaps, standards, and operational reviews

Senior Business Systems Analyst

General

• Request and obtain medical records from healthcare providers
• Collect medical records within tight timeframes and facilitate storage in secure organizational repositories
• Track and document activity completely and accurately in all systems
• Contact provider offices and facilities to request medical records and serve as the point of contact for medical record request inquiries
• Identify and coordinate efficient retrieval methods, including onsite retrieval, secure electronic access, and secure web upload
• Ensure complete EMR information is obtained and necessary information is retrieved
• Prepare hard copy medical records for conversion into electronic images
• Communicate with team members and external healthcare providers to meet strict project deadlines
• Travel to provider offices, medical facilities, or Highmark campus to obtain and prepare medical records
• Perform other duties as assigned or requested

Medical Record Retrieval Specialist

Architect

• Lead the development and articulation of complex architecture vision and strategy aligned with business goals and strategic initiatives
• Champion adoption of best practices and emerging technologies to drive innovation and continuous improvement
• Collaborate with senior stakeholders across the organization and influence architectural decision-making
• Lead evaluation and selection of new technologies and solutions
• Develop and maintain comprehensive architectural documentation
• Identify and mitigate risks and challenges affecting complex architectures
• Serve as a subject matter expert and advocate for architectural best practices
• Contribute to organizational standards and policies
• Provide expert guidance and mentorship to a team of architects
• Foster collaboration and knowledge sharing
• Perform other duties as assigned or requested
• Focus on the Front Office application ecosystem, including Sales, Marketing, and Digital

Principal Architect

Nurse Practitioner

• Provide specialty and critical care healthcare services in physician offices and non-acute settings, focusing on chronic health conditions
• See hepatology patients in clinic Monday-Friday
• Perform hospital rounding as needed
• Provide weekend coverage as needed
• Record patient medical histories and physical assessments
• Develop therapeutic care plans and order, interpret, and evaluate diagnostic studies
• Make medical diagnoses and institute appropriate therapy within scope and standards of practice
• Provide emergency treatment and stabilization in acute situations
• Document in the EMR and report pertinent information to the attending physician
• Educate patients and families about prevention, medications, and treatment
• Communicate with attending physicians and involve them in clinical decision-making
• Maintain continuing education and participate in patient safety, quality improvement, and patient engagement initiatives
• Perform specialty-specific procedures and meet expectations established through privileging and job agreements

Physician Assistant or Nurse Practitioner – Outpatient Domain, Hepatology

Analyst

• Support development, execution, and maintenance of automated testing solutions for clinical and business applications
• Work with Epic analysts, application teams, business stakeholders, and vendors to design, build, execute, and maintain UiPath automated test scripts
• Document business processes and develop and maintain automation scripts
• Execute test scenarios, analyze results, troubleshoot issues, and validate outcomes
• Support continuous improvement initiatives and workflow validation for Epic and other healthcare applications
• Assist senior team members and cross-functional teams in capturing capability needs and delivering quality business solutions
• Assist with business vision, requirements, client personalization, and user interface design deliverables
• Support requirements testing, including test plans, scenarios, documentation, and defect management
• Analyze testing results in relation to customer impacts and help minimize production defects
• Ensure compliance with required standards and obtain necessary project approvals
• Assist with requirement walkthroughs and sprint reviews, report project status, enable vendor solutions, and provide documentation
• Perform other duties as assigned

Clinical Testing Automation Analyst

Software Engineer

• Build scalable software applications across all digital channels
• Take an enterprise-wide architectural view of solutions and execute products using an appropriate technical stack
• Participate in the full software application build process, from idea generation and business analysis through technical design and software development
• Analyze, design, code, test, and implement complex application enhancements
• Provide production support while meeting scope, target dates, and budgets with minimal or no defects
• Participate in the full system development life cycle according to Highmark SDLC standards
• Collaborate with customers, business analysts, partners, and IT team members to understand business requirements and design technical solutions
• Provide technical support, including release implementations, on-call support, and 24x7 support when necessary
• Participate in project teams as Developer, Technical Lead, or Project Manager, depending on experience
• Communicate with team members, customers, partners, and management
• Conduct or assist with technical walkthroughs, report project status, enable vendor solutions, and produce accurate documentation
• Perform other duties as assigned

Senior Application Developer

Dietitian

• Assess patient need for diabetes education
• Provide individualized diabetes self-management education/training based on assessment
• Plan and conduct continuing education programs for professional staff and the community
• Collect DSME/T program participant assessment data using a recognized certification database/program collaboratively and continuously
• Develop educational goals, learning objectives, educational content, and teaching methods with program participants
• Collaboratively develop individualized follow-up plans with program participants
• Evaluate educational service effectiveness by measuring attainment of learning objectives
• Conduct follow-up assessments after completion of DSME/T program services using AADE7 Continuum of Outcomes Framework measures
• Document assessment data, educational plans, services provided, and evaluation results in participant educational records
• Participate in developing education curricula and materials
• Perform other assigned or required duties

Certified Diabetes Educator, Dietitian

Representative

• Process provider applications and re-applications, including initial mailing, review and loading
• Maintain the provider database
• Communicate with providers by phone and mail regarding credentialing status and information
• Perform credentialing, re-credentialing and related activities
• Coordinate credentialing verifications
• Review and process complex additions, updates and deletions of provider information in the Dental Provider file database
• Support implementation of new networks, systems, software, guidelines and other initiatives, focusing on group practices
• Train credentialing personnel depending on level
• Manage credentialing inventory, reports and projects to meet established timelines
• Create and distribute monthly reports
• Handle complex, unusual and high-level credentialing issues
• Support projects, audits, business partners, internal departments and external clients
• Represent the department as the subject matter expert
• Research and pull documentation for audits
• Provide customer oversight for unique requirements and timelines
• Investigate interim license actions depending on level
• Participate in projects that streamline, automate or enhance credentialing functions

Credentialing Representative

Account Manager

• Serve as primary relationship owner and executive liaison for strategically aligned provider groups within the Highmark Network
• Manage and optimize assigned provider relationships across ancillary networks, independent physician organizations, and integrated delivery networks
• Support and execute Value-Based Reimbursement performance improvement initiatives
• Identify and drive Total Cost of Care reduction opportunities
• Lead VBR activities, provider education, and implementation of new tools
• Communicate with business leaders regarding VBR participation, opportunities, performance, and progress
• Use resources, tools, analytics, and reports to improve health outcomes, lower unit costs, and increase patient satisfaction
• Educate providers on medical expense management and HEDIS and STAR metrics
• Lead provider relationships to prevent problems, improve operational efficiencies, and achieve corporate objectives
• Educate providers on reimbursement policies, processing requirements, and technology offerings
• Maintain communication with provider contacts through personal contacts, field visits, regional sessions, and professional organization meetings
• Coordinate with contracting, operations, and support areas on initiatives, communications, and issue resolution
• Triage provider issues and route communications to appropriate departments
• Convey provider feedback to internal teams and represent the department on cross-functional teams and corporate initiatives
• Maintain market, industry, and healthcare innovation knowledge
• Perform other duties as assigned