Pharmacist: Prior Authorization & Coverage Decisions

Highmark Health; Pennsylvania; Hybrid; USD 103,000 - 165,000; Full time

Job summary

Highmark Inc. in the United States seeks a pharmacist to review medication coverage requests for prior authorization and appeals. Using the Utilization Review system, you evaluate clinical information against medical policy to make determinations.

You will research beyond policy as needed and ensure records are updated for proper routing and payment. Occasional travel not required; the role is office-based with emphasis on accuracy, compliance, and clear communication.

Qualifications

• Pharmacist license required.
• BS in Pharmacy with 1–3 years experience.
• Pharmacist licensure in good standing preferred.

Responsibilities

• Make coverage determinations by evaluating requests for prior authorization or appeals against medical policy.
• Update system records to ensure claims are properly routed and paid.
• Conduct additional research beyond medical policy to make coverage determinations.

Skills

Oral & Written Comms

General Computer Skills

Problem Solving

Compliance & Prioritizing

Education

Bachelor's in Pharmacy

Doctorate in Pharmacy

Job description

Highmark Inc. in the United States seeks a pharmacist to review medication coverage requests for prior authorization and appeals. Using the Utilization Review system, you evaluate clinical information against medical policy to make determinations.

You will research beyond policy as needed and ensure records are updated for proper routing and payment. Occasional travel not required; the role is office-based with emphasis on accuracy, compliance, and clear communication.