Pharmacist - Utilization Management (UM)- REMOTE

Company: Highmark Health
Location: Topeka
Posted on: June 22, 2022

Job Description:

**Company :** Highmark Inc. **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 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_** _: 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._ 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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. EEO is The Law Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( _) We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below. For accommodation requests, please contact HR Services Online at HRServices@ California Consumer Privacy Act Employees, Contractors, and Applicants Notice Req ID: J208091

Keywords: Highmark Health, Topeka , Pharmacist - Utilization Management (UM)- REMOTE, Executive , Topeka, Kansas