Job Description :
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 Job Functions:
- 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.
- High School Diploma/GED
- 1 – 3 years of Customer Service experience
- 0 – 1 year of experience working in the Healthcare Industry
- 0 – 1 year of experience working in the Health Insurance Industry
- 0 – 1 year of experience working within a Call Center related environment
Referral Bonus: Level 1
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 position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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.
EEO is The Law
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