About the position This job captures all inbound inquiries 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.

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.

Requirements

• 1 year of Customer Service experience
• 1 year of Healthcare Industry
• 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.
• High School/GED
• None