Company :

Job Description : 

JOB SUMMARY

This job captures all inbound phone inquires for utilization management review from providers and pharmacies. The incumbent assesses the verbal request, critically thinks through the inquirer's concerns which may require research to fulfill the call, such as verifying benefit coverage, creation of a prior authorization case in Highmark's Utilization Management system for Prior Authorization clinical review, status research, etc.  Ensures all accurate information is verified and entered at the onset of the process to ensure adherence to all regulatory compliance requirements and service level agreements.  This role may be required to make outbound calls, triage cases, and/or build cases if inventory levels require support. 
 

ESSENTIAL RESPONSIBILITIES

• Handle all inbound phone requests from providers or pharmacy for all inbound Prior Authorization requests.  Use multiple software systems and various resource sites to determine member plans and requirements while gathering all appropriate documentation including verification of benefit eligibility. Ensure conversation highlights are captured within the system.  If required, build cases in the utilization management system.
• Utilize critical thinking to ensure call is being appropriately responded to while gathering all required documentation.  Appropriately evaluate call and determine if de-escalation is required.
• Ensure accuracy of data entry to prevent compliance and/or downstream process issues.
• Other duties as assigned or requested

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EDUCATION

Required

• High School Diploma/GED

Substitutions

• None

Preferred

• None

EXPERIENCE

Required

• 3 years of customer service experience
• 1 year of healthcare industry experience ​

Preferred

• None

LICENSES AND CERTIFICATION

Required

• None

Preferred

• None

SKILLS

• Possess good written and oral telephonic communication skills
• Ability to navigate through multiple systems simultaneously
• Knowledge of administrative and clerical procedures and systems such as word processing, managing files and digital fax
• Ability to interact well with peers, supervisors, and customers
• Problem-Solving
• Knowledge of principles and processes for providing customer service.  This includes customer needs assessment, meeting quality standards for services

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Language (Other than English)

None 

Travel Required

0%  - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Frequently

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

Occasionally

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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