Highmark Health

• Design, develop, and maintain robust data processes and solutions to ensure the efficient movement and transformation of data across multiple systems • Develop and maintain data models, databases, and data warehouses to support business intelligence and analytics needs • Collaborate with stakeholders across IT, product, analytics, and business teams to gather requirements and provide data solutions that meet organizational needs • Monitor work against production schedule, provide progress updates, and report any issues or technical difficulties to lead developers regularly • Implement and manage data governance practices, ensuring data quality, integrity, and compliance with relevant regulations. • Collaborate on the design and implementation of data security measures, including access controls, encryption, and data masking • Mentor other associate and intermediate data engineers as needed • Perform data analysis and provide insights to support decision-making across various departments • Stay current with industry trends and emerging technologies in data engineering, recommending new tools and best practices as needed

• Reviews and interprets medical information, physician treatment plans, course, and outcome to determine appropriate ICD-10 CM/CPT codes for diagnoses and procedures. ( 65%) • Abstracts data elements to satisfy statistical requests by the hospital, health system, medical staff, etc. and enters all coded/abstracted information into designated system. ( 15%) • Ensures efficient management of medical information and cash flow as it pertains to the unbilled coding report. ( 10%) • Keeps informed of the changes/updates in ICD-10 CM/CPT guidelines by attending appropriate training, reviewing coding clinics and other resources and implementing these updates in daily work. ( 5%) • Performs other duties as assigned or required. (5%)

Role Description This job implements effective utilization management strategies including: - Review of appropriateness of health care services - Application of criteria to ensure appropriate resource utilization - Identification of opportunities for referral to a Health Coach/case management - Identification and resolution of quality issues Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives. Qualifications - Required: None - Preferred: Bachelor’s Degree in Nursing Requirements - Required: 3 years of related, progressive clinical experience in the area of specialization - Required: Experience in a clinical setting - Preferred: Experience in UM/CM/QA/Managed Care Benefits - Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) - Preferred: Certification in utilization management or a related field Skills - Working knowledge of pertinent regulatory and compliance guidelines and medical policies - 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 Travel Requirement - 0% - 25% 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: Does Not Apply - Works primarily out-of-the office selling products/services (sales employees): Does Not Apply - Physical work site required: Yes - Lifting: up to 10 pounds: Constantly - Lifting: 10 to 25 pounds: Occasionally - Lifting: 25 to 50 pounds: Rarely, Occasionally

Role Description This job performs accurate and timely processing of pre-certification requests for authorization of medically necessary health care services, at the appropriate level of care, based on the benefits for the line of business, and in compliance with the organization's policies, procedures and regulatory requirements. Documents, processes and routes requests for services to the nurse reviewer and other departments based on documentation procedures, including review type, clinical information, and decision timeframes. Follows policies and procedures to assure case completion and compliance with state and federal regulatory agencies. Maintains or exceeds department standards for call volume, response time and related production and quality measures. May interact with other departments and providers to resolve cases. Qualifications - 3 years of experience in customer service - 3 years of experience in typing, keyboard and computer skills - 3 years of work experience in medical terminology - Preferred: Work experience with ICD-9 and/or CPT coding - Required: High School diploma / GED - Preferred: Associates degree or certification in a health related occupation Requirements - Proactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are met. - Communicate effectively with Utilization Management Staff, providers, other internal and external customers and management. - Route Cases Based on Established Guidelines. - Provide accurate and timely routing of service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelines. - Process service requests meeting established guidelines, and document and route requests that are not permitted. - Request additional information verbally and in writing when the information provided is not adequate to make a medical necessity determination. - Escalate appropriate cases to leadership that require a clinical review and/or other intervention. - Assist with reporting as directed. - Participate in precepting of new employees, as assigned. - Maintain or exceed department call center standards. - Adhere to line of business phone standards to assure regulatory requirements are met. - Utilize phone functions to monitor the number of calls in queue and wait time. - Utilize daily phone standard reports to assess opportunities for self-improvement. - Meet or exceed standards for other production and quality measures. - Other duties as assigned or requested. Benefits - Pay Range Minimum: $21.96 - Pay Range Maximum: $32.95 - Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. 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. Employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. 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.

Role Description This role is responsible for managing all aspects of post-acute care contracting, with a specific focus on home health, hospice, and skilled nursing facilities. The Provider Contract Analyst will be involved in the entire contract lifecycle, including negotiations, development, and ownership changes ensuring favorable financial reimbursement and compliance with all contractual terms. This position acts as a critical intermediary between the organization and external entities, proactively addressing contractual and payment issues both internally and externally. The analyst will be heavily involved in provider-facing activities such as assisting with the Helion Provider Help Desk to answer questions related to Utilization Management and claims processing, collaborating with the development team to draft agreements, and assisting with health plan contract negotiations. This is a remote-based role; however, the candidate is preferred to be in the Western, PA territory. Qualifications - Associates degree in Business, Finance, Information Management, Healthcare Administration or Health Related Discipline (Required) - Bachelor's degree in business, finance, information management, healthcare administration or health related discipline (Preferred) - 5 years experience in health care administration/delivery/finance or a related field (Required) - MBA or CPA (Preferred) Requirements - Monitor activities by tracking the specific terms of each contract and maintaining compliance documentation. - Prepare periodic reports summarizing compliance with key responsibilities outlined in agreements. - Conduct, collect, and analyze data from claim and/or medical record reviews. - Manage contracts including negotiations, contract development, contract renewal, and financial reimbursement. - Act as the intermediary between the organization and outside entities. - Participate in educational and training sessions for provider billing staff. - Provide control and processing support for final provider settlements. - Work with sales and customer service to respond to inquiries from customers/members. - Consult with Medical Director on questions/issues related to medical necessity. - Other duties as assigned or requested. Benefits - Base pay range: $68,400.00 - $105,900.00 - Pay determined by qualifications, experience, and expected contributions.

• Deliver value to the Health Plan and its beneficiaries enrolled in risk-adjusted government programs through HCC coding, medical coding, clinical terminology and anatomy/physiology • Conduct quality assurance (QA) review of internal coding team members • Provide coding education to team • Evaluate HCC coding questions and independently renders guidance on appropriate coding determinations • Supports RADV audits • Specializes in performing second level review of HCC validation • Prepares documentation and coversheets for upload to regulatory body and/or independent auditor • Analyzes results • Develop presentations to improve provider documentation and accuracy • Conducts Quality Assurance (QA) reviews on internal coders • Guides coding decision making adhering to CMS Guidelines for Coding and Highmark’s Policy and Procedures

Role Description This job is responsible for working accounts from work queues; activities include analysis (including root cause), monitoring & auditing payer issues and denials, appealing RAC audits and reports that require well-developed analytic and organizational skills, while meeting deadlines. Working under the close cooperation with others in the department to communicate and/or enhance work flows and procedures by identifying training and development needs based on audit or workqueue trends. Essential Responsibilities - Reviews, analyzes and resolves accounts that have failed coding and charging related claim edits, including medical necessity, National Correct Coding Initiative (NCCI), Medicare Outpatient Code Editor (OCE), Medically Unnecessary Edits (MUE), and other exceptions requiring clinical/coding expertise. Works to resolve rejections and accounts flagged for potential missing charges. (50%) - Completes payor audits. Researches and evaluates government regulations and third party payor requirements to ensure accurate error resolution and appropriate billing. (30%) - Daily assessment of blood bank report and reconciliation, and supply chain for mapping and charge validation. (20%) - Working with other department members on establishment of work plans to correct identified deficiencies, providing guidance, communication and education on correct charge capture, coding and billing processes. (10%) - Other duties as assigned. Qualifications - Minimum: High School/GED - 1 year of hospital or physician revenue cycle, billing, or coding experience - Preferred: Associate's Degree 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. Pay Range - Minimum: $25.87 - Maximum: $40.48 Equal Opportunity Statement 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. Accessibility We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

Role Description This job builds and maintains hospital, professional, and ASC contracts in Epic. Identifies underpaid accounts and articulates the source of the processing error to the payor. - Provides support to senior analysts in building hospital, professional, and ASC contracts in Epic. (40%) - Manages underpayment AR for assigned payors including successfully recovering on underpaid accounts. (25%) - Collaborates with Revenue Cycle and Finance Teams on contract building and analysis requests. (25%) - Provides assistance in performing analyses to support reimbursement impact analysis. (10%) - Perform other duties as assigned or required. Qualifications - Minimum: - Associate's degree in Finance, Accounting, Business Administration, Economics, Statistics, or Related Field - Experience in finance, contracting, or data analysis - Microsoft Office (Excel, PowerPoint, etc.) - Ability to analyze and interpret various types of data including financial results, operational metrics, clinical outcomes, and other key datasets - Ability to work with large quantities of detailed data and illuminate the higher-level strategic insights that can impact business operations and performance - Ability to juggle multiple projects at once and manage time effectively, in order to meet established deadlines - Strong oral and written communication skills - Ability to independently make progress on key projects with support from supervisor or peer analysts - Preferred: - Bachelor's degree in Finance, Accounting, Business Administration, Economics, Statistics, or Related Field - Epic Expected Reimbursement Contracts Certification - Experience with hospital, physician, and ASC contracts - Experience in healthcare - R, Python, or other statistical/programming tools - Knowledge of healthcare industry, particularly as it relates to hospitals or other providers reimbursement methodologies - Clinical background or general understanding of hospital/physician practice operations Requirements This section is intentionally left blank. Benefits This section is intentionally left blank. Company Description This section is intentionally left blank.

Role Description This job is responsible for medical research and developing utilization management pre-certification criteria for medical policies to be used by review, utilization, and case management nurses. Code changes into claims systems using national coding structure for processing accuracy and clinical appropriateness once medical policy has been established. Serves as a liaison to business units for correct coding of claims. Researches questions and issues from internal physicians and nurses as they relate to the development of medical policies. Essential Responsibilities - Responsible for the research, analysis, development, maintenance, coordination, and documentation of medical policy for the Organization’s entire Commercial and Medicare Advantage lines of business and all products. - Accountable for coordinating and ensuring that the appropriate system changes are implemented in concert with policy development and revisions. - Responsible for reviewing and analyzing all new, revised and deleted procedure codes published quarterly by the Centers for Medicare and Medicaid Services, the Blue Cross and Blue Shield Association, and the American Medical Association. - Evaluation of potential impacts to medical policy and initiates applicable policy revisions. - Coordinate database functions and policy issues with internal departments regarding Health Care Code System (HCCS) functions and policy issues. - Review the International Classification for Diseases, (ICD-9, ICD-10) diagnosis code update for potential impacts to the database functions and policy issues. - Responsible for all coordination necessary related to policy maintenance and evaluates its impact to policy application and claims adjudication. - Review and comment on all policy circulations within the department. - Review all policy drafts for accuracy and respond appropriately to the author of the policy. - Research inquiries and make policy decisions and/or recommendations to management. - Respond to inquiries from both internal and external sources. Inquiries may require extensive research. Must be able to explain and support the rationale for the policy position in order to respond to physician inquiries, internal inquiries, legal depositions, and vendors. - Research, develop and document topics for presentation (The Organization's Clinical Policy Management Committee (CPMC) or specialty Subcommittee). These evaluations require detailed analysis and interpretation of highly technical literature and clinical publications. - Review procedures and/or devices identified as potentially experimental. - Periodically review all procedures that are currently classified as experimental/investigational and make a recommendation whether to retain the investigational status to management. - Review new and revised BCBSA medical policies. - Evaluate and compare all new and revised BCBSA medical policy bulletins to the Organization's medical policies. - Make recommendations to management concerning the adoption of the BCBSA new policies or revisions. - Other duties as assigned or requested. Qualifications - Minimum: Bachelor’s degree or clinical license/certification in lieu of bachelor's degree. - 5-10 years of relevant, progressive experience in the area of specialization. - Experience with medical policy development, contractual provisions, commercial claims and/or medical/surgical products or Medicare Advantage or Medicare Fee for Service program coverage, the Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-9, ICD-10) information, project management, and Highmark claims processing requirements, and pricing mechanisms. - Preferred: Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Registered Nurse Practitioner (CRNP). - Certified Professional Coder. - Experience in researching and interpreting clinical literature. - Well-developed computer and clinical research experience. - Knowledge of the OSCAR claims processing system. Knowledge, Skills and Abilities - Experience with a PC and common software applications to include Web research. - Ability to analyze CMS documents such as transmittals and the Federal Register. - Excellent verbal and written communication skills. - Independent assessment and excellent time management skills; multi-tasking accountability. - Well-developed computer and clinical research experience. - Knowledge of the OSCAR claims processing system. Work Environment - Does this role supervise/manage other employees? No. - Is Travel Required? No. 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. 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. Pay Range - Pay Range Minimum: $68,400.00 - Pay Range Maximum: $105,900.00 Equal Opportunity Statement 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. Accessibility Statement We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org.

• Lead product management efforts focused on the Acquisition & Onboarding portfolio within the Government segment • Define and execute strategies that drive membership growth and enhance member retention • Optimize the onboarding experience to foster engagement and confidence among government members • Conduct market research, competitive analysis, and customer insights to identify unmet needs • Develop new products and experiences that create durable customer and business value • Socialize product strategy and roadmap with key stakeholders and obtain buy-in • Develop and maintain a comprehensive multi-year product roadmap that aligns with the company's strategic goals • Lead the product development process from ideation to launch • Manage product backlog, prioritize features, and track progress against timelines, budgets, and value realization • Monitor product performance metrics and implement strategies for product optimization • Build, mentor, and lead a high-performing team of product managers and analysts