Pharmacist - Utilization Management (UM) - (Remote)

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. For accommodation requests, please contact HR Services Online at View email address on click.appcast.io. California Consumer Privacy Act Employees, Contractors, and Applicants Notice #J-18808-Ljbffr