Company :

Job Description : 

JOB SUMMARY

*** This position is a Hybrid position, Tue/Wed/Thur in the office and Work from home on Mon/Fri ****

This job captures all inbound inquires for utilization management review from providers and pharmacies.  The incumbent assesses the request, conducts all necessary research such as verifying benefit coverage for the member, and then creates the case (data entry) in Highmark's Utilization Management system for Prior Authorization 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, Predictal Availity portal and/or service form inquiry.  At times may require follow-up communication with the requestor's office (physicians or pharmacists).  This role may be required to make outbound calls and/or triage cases if inventory levels require support. 

ESSENTIAL RESPONSIBILITIES

• Obtain requests from provider or pharmacy via fax, provider portal or service form inquiry.   May obtain requests from provider or pharmacy by phone in some areas of the organization.  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, outreach to providers and/or pharmacists may be required to obtain additional information.  
• Ensure accuracy of data entry to prevent compliance and/or downstream process issues.
• Other duties as assigned or requested.

EXPERIENCE

Required

• 1 year of Customer Service experience
• 1 year of Healthcare Industry

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SKILLS

• Possess good written and oral telephonic communication skills
• Ability to navigate through multiple systems simultaneously
• Knowledge of administrative and clerical procedures and systems such as word processing, managing files and digital fax
• Ability to interact well with peers, supervisors, and customers
• Problem-Solving
• Knowledge of principles and processes for providing customer service.  This includes customer needs assessment, meeting quality standards for services.

EDUCATION

Required

• High School/GED

LICENSES or CERTIFICATIONS

Required

• None

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office- This position is a Hybrid, Tue/Wed/Thur in the office and Work from home on Mon/Fri

Teaches / trains others

Occasionally

Travel 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

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

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.

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.

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