Company :

Job Description : 

JOB SUMMARY

This job 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.

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. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

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.

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