Pharmacist - Prior Authorization & Coverage Review

highmarkhealth; Pennsylvania; Hybrid; USD 103,000 - 165,000; Full time

Job summary

Highmark Inc. reviews requests for medication coverage determinations for prior authorization review and appeals.

Through the Utilization Review system, the pharmacist evaluates clinical information against medical policy criteria to make determinations. The role requires a Bachelor’s in Pharmacy and a registered Pharmacist license; 1–3 years’ experience in pharmacy is preferred, with potential for Doctorate in Pharmacy.

Qualifications

• Bachelor's degree in Pharmacy required.
• 1–3 years of experience in pharmacy.
• Licensed Pharmacist required.
• Preferred: Doctorate degree in Pharmacy.
• Strong communication, problem solving, and compliance skills.

Responsibilities

• Make coverage determinations by evaluating physician requests for prior authorization or appeals against medical policy through the Utilization Review system.
• Conduct research beyond medical policy review to make decisions on medication coverage requests.
• Other duties as assigned.

Skills

Oral & Written Communication Skills

General Computer Skills

Problem Solving & Decision Making

Compliance

Prioritizing

Education

Bachelor's degree in Pharmacy

Doctorate degree in Pharmacy

Job description

Highmark Inc. reviews requests for medication coverage determinations for prior authorization review and appeals.

Through the Utilization Review system, the pharmacist evaluates clinical information against medical policy criteria to make determinations. The role requires a Bachelor’s in Pharmacy and a registered Pharmacist license; 1–3 years’ experience in pharmacy is preferred, with potential for Doctorate in Pharmacy.