Pharmacist - Utilization Management (UM) - (Remote)

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

Company

Highmark Inc.

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 Pharmacist; Preferred: 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-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

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

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

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.

Non-Discrimination

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. We endeavor to make this site accessible to any and all users.

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About Highmark Health

Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.