This job captures all inbound phone inquiries for utilization management review from providers and pharmacies. The incumbent assesses the verbal request, critically thinks through the inquirer's concerns which may require research to fulfill the call, such as verifying benefit coverage, creation of a prior authorization case in Highmark's Utilization Management system for Prior Authorization clinical review, status research, etc. Ensures all accurate information is verified and entered at the onset of the process to ensure adherence to all regulatory compliance requirements and service level agreements. This role may be required to make outbound calls, triage cases, and/or build cases if inventory levels require support. Essential responsibilities include handling all inbound phone requests from providers or pharmacy for all inbound Prior Authorization requests, using multiple software systems and various resource sites to determine member plans and requirements while gathering all appropriate documentation including verification of benefit eligibility, ensuring conversation highlights are captured within the system, building cases in the utilization management system if required, utilizing critical thinking to ensure call is being appropriately responded to while gathering all required documentation, appropriately evaluating calls and determining if de-escalation is required, ensuring accuracy of data entry to prevent compliance and/or downstream process issues, and performing other duties as assigned or requested. The position requires a High School Diploma/GED, 3 years of customer service experience, and 1 year of healthcare industry experience. Skills required include good written and oral telephonic communication skills, ability to navigate through multiple systems simultaneously, knowledge of administrative and clerical procedures and systems, ability to interact well with peers, supervisors, and customers, problem-solving skills, and knowledge of customer service principles and processes. The position is office-based, on-site only, with 0% - 25% travel required. Compliance with HIPAA and company policies is mandatory.
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