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Pharmacist - Utilization Management (UM)
Permanent (Full time)
Company :Highmark IncJob Description :JOB SUMMARYThis 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 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 QUALIFICATIONS+ Bachelor's Degree in Pharmacy
- 1 - 3 years in PharmacyPreferred+ Doctorate Degree in PharmacyLICENSES OR CERTIFICATIONSRequired+ Registered PharmacistSKILLS+ Oral & Written Communication Skills
- General Computer Skills
- Problem Solving & Decision Making
- PrioritizingPHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition TypeOffice-Based
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
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 Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company
_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 Companys Handbook of Privacy Policies and Practices and Information Security
_Furthermore, it is every employees responsibility to comply with the companys 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
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, 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, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity ( ###### )
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Req ID: J173680
Posted 9 days ago