Highmark Health Medical Review Clinician-2 in Pittsburgh, Pennsylvania



This position requires not only the fundamental skillset to perform a prospective/concurrent review but also the ability to identify issues related to professional and facility provider claims data including determining appropriateness of code submission, analysis of the claim rejection and the proper action to complete the retrospective review with the goal of proper and timely payment to provider and member satisfaction. The Medical Review Clinician is responsible for the implementation of effective utilization management strategies on a prospective, concurrent and retrospective claims review basis. The retrospective claims review process includes a review of both medical documentation and claims data to assure appropriate resource utilization, identification of opportunities for Case Management, identify issues which can be used for education of network providers, identification and resolution of quality issues and inappropriate claim submission. The Medical Review Clinician is expected to utilize specialized skills and knowledge to achieve successful and measurable outcomes. The Medical Review Clinician monitors and analyzes the delivery of health care services in accordance with claims submitted, and analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction. Medical Review Clinician is expected to identify potential discrepancies in provider billing practices and intervene for resolution and education or if necessary involve Special Investigation Unit.


  1. Implements the prospective, concurrent and retrospective review processes that are consistent with established industry and corporate standards and are within the Medical Review Clinician’s professional discipline. Effectively functions in accordance with applicable state, federal laws and regulatory compliance.

  2. Implements all retrospective reviews according to accepted and established criteria (InterQual), as well as other approved guidelines and medical policies. Promotes quality and efficiency in the delivery of retrospective review services.

  3. Respects the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws. Practices within the scope of ethical principles.

  4. Identifies and refers members whose healthcare outcomes might be enhanced by Case Management or Condition Management interventions. Employs collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes.

  5. Identify issues which can be used to educate professional and facility providers and vendors for the purpose of streamlining and improving processes. Develops and sustains positive working relationships with internal and external customers.

  6. Utilizes outcomes data to improve ongoing care management services.

  7. Other duties as assigned or requested.



• RN (Registered Nurse) license

• 3-5 years of related, progressive experience in a clinical setting.


• Bachelor’s degree in a field related to licensure

• Certification in utilization management or a related field

• 1-3 years of experience in UM/QA/Managed Care

Knowledge, Skills and Abilities

• Working knowledge of pertinent regulatory and compliance guidelines and medical policies

• Experience with reviewing analyzing professional and facility provider claims data

• Experience with CPT/HCPCS codes

• Proficiency in utilizing PC applications accessed by Medical Review

• Ability to multi task and perform in a fast paced and often intense environment

• Excellent written and verbal communication skills

• Ability to analyze data, measure outcomes, and develop action plans

• Be enthusiastic, innovative, and flexible

• Be a team player who possesses strong analytical and organizational skills

• Demonstrated ability to prioritize work demands and meet deadlines

• Excellent computer and software knowledge and skills

IV. SCOPE OF RESPONSIBILITY (People Management Responsibility)

Does this role supervise/manage other employees?



Is Travel Required?



Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity