Company :
Highmark Inc.
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:
$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.
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
California Consumer Privacy Act Employees, Contractors, and Applicants Notice
Req ID: J277819
...enriching, and meaningful game titles such as Sky, Journey, Flower, and flOw. Our 3rd party publishing team is seeking a Social Media & Community Manager to shape how our games live and breathe online. You will own both our publishing label and partner channels, building...
...At Magical Destinations Travel Agency, we curate unforgettable vacations for our clients from romantic honeymoons to bucket-list adventures... .... Were looking for a passionate Remote Luxury Vacation Planner to join our team and help travelers create once-in-a-lifetime experiences...
...The Recruiter develops, negotiates, and implements partnerships with traveling long-term care, allied and nursing healthcare professional across the nation. The Recruiter position is integral in sourcing new caregivers and has the ability to make a difference in healthcare...
Class A Class A - Heavy Haul Truck Driver JobA family-owned trucking company based in Richmond, Kentucky is looking for experienced heavy-haul drivers to... ...well maintained equipmentNO slip seatingWe are a small, family owned company with less than 15 employees. You...
...Requisition No:870237 Agency: Florida Fish and Wildlife Conservation Commission Working Title: OPS Fish & Wildlife Technician - 77902297Pay Plan: Temp Position Number:77902297 Salary: $16.83 an hour Posting Closing Date: 03/15/2026 Total Compensation...