Description
JOB SUMMARY
This position requires the candidate to work Sunday's as part of their assigned shifts
This job captures all inbound requests for utilization review from providers and pharmacies. The incumbent assesses the request, conducts all necessary research such as verifying benefit coverage for the patient, and then creates the case (data entry) in Highmark's utilization management system for clinical review.
Ensures all accurate information is entered at the onset of the process to ensure adherence to all regulatory compliance requirements and service level agreements.
The requests may come via fax or phone, and at times may require follow-up calls with physicians or pharmacists.
ESSENTIAL RESPONSIBILITIES
- Obtain requests from provider or pharmacy via phone, fax, or provider portal (online). Use multiple software systems and various resource sites to determine member plans and requirements.
- Gather all required documentation including verification of benefit eligibility. Build cases in the utilization management system.
- Use knowledge of process and judgement to evaluate identified cases that require additional notification to member, provider, and / or pharmacist.
At times, contact by phone members, providers and / or pharmacists to obtain additional information.
- Ensure accuracy of data entry to prevent compliance and / or downstream process issues.
- Other duties as assigned.
EDUCATION
Required
High School Diploma / GED
Substitutions
None
Preferred
None
EXPERIENCE
Required
- 1 - 3 years of Customer Service experience
- 0 - 1 year of experience working in the Healthcare Industry
Preferred
0 - 1 year of experience working in the Health Insurance Industry
LICENSES AND CERTIFICATIONS
Required
None
Preferred
None
SKILLS
- Oral & Written Communication Skills
- Telephone Skills
- Problem Solving & Decision Making
- Compliance
- Healthcare Industry
- Health Insurance
Language (Other than English)
None
Travel Required
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-Based
Teaches / trains others regularly
Rarely
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
Lifting : up to 10 pounds
Occasionally
Lifting : 10 to 25 pounds
Rarely
Lifting : 25 to 50 pounds
Rarely
Pay Range Minimum : $19.27
$19.27
Pay Range Maximum : $26.88
$26.88
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 their race, color, age, religion, sex, national origin, sexual orientation / gender identity or any other category protected by applicable federal, state or local law.
Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation / gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities / Women / Protected Veterans / Disabled / Sexual Orientation / Gender Identity ()
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