Description

JOB SUMMARY

This job captures all inbound inquires 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.

ESSENTIAL RESPONSIBILITIES