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.
- 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
LICENSES AND CERTIFICATIONS
- Oral & Written Communication Skills
- Telephone Skills
- Problem Solving & Decision Making
- Healthcare Industry
- Health Insurance
Language (Other than English)
Pay Range Minimum:
Pay Range Maximum: