[Hiring] Pharmacist - Utilization Management @Highmark Health

Role Description

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.

• 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.

Qualifications

• Required: Bachelor's degree in Pharmacy
• Preferred: Doctorate degree in Pharmacy

Requirements

• 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

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

Pay Range

• Pay Range Minimum: $102,700.00
• Pay Range Maximum: $164,600.00

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.

Equal Opportunity Statement

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.

Accessibility

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For accommodation requests, please contact HR Services Online at [email protected]

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