Job Description

Job Opportunity At Highmark Inc.

Job Summary: This position reviews requests for medication coverage determination for prior authorization review and appeals. Through the Utilization Review system, the incumbent evaluates clinical information provided by the physician against medical policy criteria. The incumbent then uses his/her clinical knowledge compared to the policy and physician request to make a determination. At times, the incumbent may conduct additional research beyond medical policy review to make coverage determinations.

Essential Responsibilities:

• Make coverage determinations by evaluating physician requests for prior authorization or appeals against medical policy through the Utilization Review system. Update the system records appropriately to ensure claims are properly routed and paid.
• Conduct research beyond medical policy review to make decisions on medication coverage requests.
• Other duties as assigned.

Education:

• Required: Bachelor's degree in Pharmacy
• Substitutions: None
• Preferred: Doctorate degree in Pharmacy

Experience:

• Required: 1 - 3 years in Pharmacy
• Preferred: None

Licenses or Certifications:

• Required: Registered Pharmacist Preferred: None

Skills:

• Oral & Written Communication Skills
• General Computer Skills
• Problem Solving & Decision Making
• Compliance
• Prioritizing

Language Requirement (other than English): None

Travel Required: None

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 Rarely Works primarily out-of-the office selling products/services (sales employees) Never
• Physical work site required: Yes
• Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Rarely Lifting: 25 to 50 pounds Rarely

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

Pay Range Minimum: $67,500.00 Pay Range Maximum: $126,000.00 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. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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.

Job Tags

Work at office, Local area,

Similar Jobs