Charleston, West Virginia

**Company :**

Highmark Inc.

**Job Description :**

**JOB SUMMARY**

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

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 position 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._

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.

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 ( _https://www.eeoc.gov/sites/default/files/migrated\_files/employers/poster\_screen\_reader\_optimized.pdf_ )

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 number below.

For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Req ID: J191687

Charleston, West Virginia

Invest in yourself by becoming part of the Highmark Health enterprise! Build and grow your career with the tools and resources you need to be successful in our innovative and transformational environment. From new hire training to advanced education opportunities, career planning is a continuous journey that leads to your personal and professional growth and our success.

Whether your focus is nursing, information technology, actuarial, finance, marketing, sales, operations or one of our many other professions, our companies offer opportunities to develop and expand your career while making health care accessible, understandable and affordable for our millions of members, patients and customers.

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