Pharmacist - Utilization Management (UM) - Remote

Highmark Health; Northern (KY); Hybrid; USD 103,000 - 165,000; Full time

Job summary

Highmark Health seeks a Pharmacist to review prior authorization requests for medications and appeals. You will evaluate clinical information against medical policy criteria and determine coverage decisions using the Utilization Review system.

Office-based role in Kentucky; requires pharmacy licensure, Bachelor’s degree (Doctorate preferred), and 1–3 years of Pharmacy experience. You will also conduct policy-based research as needed and ensure records are kept accurately in the system.

Qualifications

• Pharmacist licensure required.
• Bachelor's degree in Pharmacy required; Doctorate preferred.

Responsibilities

• Make coverage determinations by evaluating prior authorization requests against medical policy.
• Conduct research beyond policy to support medication coverage decisions.
• Update system records to ensure proper routing and payment of claims.

Skills

Oral & Written Communication

General Computer Skills

Problem Solving & Decision Making

Compliance

Prioritizing

Education

Bachelor's degree in Pharmacy

Doctorate degree in Pharmacy

Job description

**JOB SUMMARY**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.**ESSENTIAL RESPONSIBILITIES*** 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.**EDUCATION****Required*** Bachelor's degree in Pharmacy**Substitutions*** None**Preferred*** Doctorate degree in Pharmacy**EXPERIENCE****Required*** 1 - 3 years in Pharmacy**Preferred*** None**LICENSES OR CERTIFICATIONS****Required*** Registered PharmacistPreferred* None**SKILLS*** Oral & Written Communication Skills* General Computer Skills* Problem Solving & Decision Making* Compliance* Prioritizing**Language Requirement (other than English)**None**Travel Required**None**PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS****Position Type**Office-BasedTeaches / trains others regularlyOccasionallyTravel regularly from the office to various work sites or from site-to-siteRarelyWorks primarily out-of-the office selling products/services (sales employees)NeverPhysical work site requiredYesLifting: up to 10 poundsConstantlyLifting: 10 to 25 poundsRarelyLifting: 25 to 50 poundsRarely***Disclaimer:** The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.* ***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.***Pay Range Minimum:**$102,700.00**Pay Range Maximum:**$164,600.00*Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.*