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Buffalo NY 1 Seneca St Ste 3400 Company: Highmark Inc.
Job 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 Highmarks 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 requestors office, physicians, or pharmacists. This role may be required to make outbound calls and/or triage cases if inventory levels require support.
ESSENTIAL RESPONSIBILITIES
• Obtain requests from provider or pharmacy via fax, provider portal, or service form inquiry. May obtain requests from provider or pharmacy by phone in some areas of the organization. • Use multiple software systems and various resource sites to determine member plans and requirements. • Gather all required documentation, including verification of benefit eligibility. • Build cases in the utilization management system. • Use knowledge of process and judgement to evaluate identified cases that require additional notification to member provider and/or pharmacist. At times, outreach to providers and/or pharmacists may be required to obtain additional information. • Ensure accuracy of data entry to prevent compliance and/or downstream process issues. • Other duties as assigned or requested.
EXPERIENCE
Required:
1 year of Customer Service experience 1 year of Healthcare Industry
SKILLS
• Possess good written and oral telephonic communication skills • Ability to navigate through multiple systems simultaneously • Knowledge of administrative and clerical procedures and systems, such as word processing, managing files, and digital fax • Ability to interact well with peers, supervisors, and customers • Problem-Solving • Knowledge of principles and processes for providing customer service, including customer needs assessment, meeting quality standards for services
EDUCATION
Required:
High School GED
LICENSES or CERTIFICATIONS
Required:
None
Language Other than English:
None
Travel Requirement:
0 - 25
PHYSICAL MENTAL DEMANDS and WORKING CONDITIONS
Position Type:
Office- or Remote-based
Teaches trains others
Occasionally:
Travel 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
No lifting up to 10 pounds
Constantly:
Lifting 10 to 25 pounds
Occasionally:
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 Companys Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employees responsibility to comply with the Companys Code of Business Conduct, which 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: $19.27 Maximum: $27.42 Base pay is determined by a variety of factors, including a candidates 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 that Highmark may apply for certain locations based upon comparative markets.
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. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServiceshighmarkhealth.org.
California Consumer Privacy Act Employees, Contractors, and Applicants Notice
Apply Job Details
Job category: Clinical Services Position Type: Full Time Posted: 2026-01-28T23:09:46.6201120000 Locations: Buffalo NY 1 Seneca St Ste 3400 Line of Business: Entity Recruiter: Recruiter Hiring Manager: Hiring Manager Experience Level: Req ID J271126
Share Facebook X LinkedIn Whatsapp Email Copy URL Apply Open in new tab icon Arrow left icon Twitter icon Facebook icon Linkedin icon Instagram icon Youtube icon Glassdoor icon Featured Links Competitively Sensitive Information Cyber Security Notice at Collection E-Verify English E-Verify - Employee Rights and Responsibilities Data Protection Sitemap Terms of Service Do Not Sell Share E-Verify Spanish Digital Privacy Policy Highmark Health is an independent licensee of the Blue Cross Blue Shield Association.
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. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServiceshighmarkhealth.org.
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Highmark provides millions of people with the security of quality health insurance
Our history of helping families and companies with their health insurance needs dates to the 1930s, when our predecessor companies were established to help Pennsylvania's residents pay for health care.
Highmark was created in 1996 by the consolidation of two Pennsylvania licensees of the Blue Cross and Blue Shield Association — Pennsylvania Blue Shield (now Highmark Blue Shield) and Blue Cross of Western Pennsylvania (now Highmark Blue Cross Blue Shield). We are now one of the largest health insurers in the United States.
Highmark's officers and board of directors set the company's strategic direction and corporate policies. They are guided by our mission, vision and values.