Process Associate-US - Military Veterans

Intake Coordinator
Aguadilla, Puerto Rico
Job Type: Full Time (Onsite)
Job Summary:
This job captures all inbound requests for utilization review from providers and pharmacies. The incumbent assesses the request, conducts all necessary research such as verifying benefit coverage for the patient, and then creates the case (data entry) in Highmark's utilization management system for 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 or phone, and at times may require follow-up calls with physicians or pharmacists.
Principal Duties and Responsibilities:

• Obtain requests from provider or pharmacy via phone, fax, or provider portal (online). 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, contact by phone members, providers and/or pharmacists to obtain additional information.
• Ensure accuracy of data entry to prevent compliance and/or downstream process issues.
• Other duties as assigned.

• High School Diploma/GED required
• 1 years of Customer Service experience required

• 0 - 1 year of experience working in the Health Insurance Industry preferred
• Prior experience working in a call center environment is a plus
• Problem Solving & Decision Making
• Compliance
• Good hold on English as a language of written, spoken and as a language of official communication in a professional environment.
• Clinical Analytic Skills.
• Excellent computer skills including experience with Microsoft Office products
• Healthcare Industry
• Health Insurance background