Highmark Health Medical Review Clinician in Wilmington, Delaware



This job performs prospective/concurrent reviews and identifies 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 incumbent implements effective utilization management strategies on a prospective, concurrent and retrospective claims review basis. Conducts the retrospective claims review process which 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 incumbent utilizes specialized skills and knowledge to achieve successful and measurable outcomes. 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. Identifies potential discrepancies in provider billing practices and intervene for resolution and education or if necessary involve Special Investigation Unit.


  • Implement 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 function in accordance with applicable state, federal laws and regulatory compliance.

  • Implement all retrospective reviews according to accepted and established criteria (InterQual), as well as other approved guidelines and medical policies.

  • Promote quality and efficiency in the delivery of retrospective review services.

  • Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws.

  • Practice within the scope of ethical principles.

  • Identify and refer members whose healthcare outcomes might be enhanced by Case Management or Condition Management interventions.

  • Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes.

  • Identify issues which can be used to educate professional and facility providers and vendors for the purpose of streamlining and improving processes.

  • Develop and sustain positive working relationships with internal and external customers.

  • Utilize outcomes data to improve ongoing care management services.

  • Other duties as assigned or requested.



  • Bachelor’s degree in a field related to licensure



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


  • 1 - 3 years in UM/QA/Managed Care



  • Active United States RN (Registered Nurse) license in any state is required upon hire. A WV license is required in addition to the home state license unless the home state license is part of the compact. The additional WV license must be obtained within the first 6 months of employment


  • Certification in utilization management or a related field


  • 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

Language Requirement (other than English)


Travel Required

0% - 25%


Position Type


Teaches / trains others regularly


Travel regularly from the office to various work sites or from site-to-site


Physical work site required


Lifting: up to 10 pounds


Lifting: 10 to 25 pounds


Lifting: 25 to 50 pounds


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 position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.


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