The purpose of this position is to process requests for insurance coverage of formulary and non-formulary drugs that reject at the dispensing pharmacy based on pre-determined plan criteria. Plan criteria are setup based on evidence based medicine and includes the exercise of appropriate clinical judgment. Prior Authorization Staff Pharmacists review all adverse coverage determinations before final decisions are rendered and, as required by law, work in conjunction with Medical Directors to render final decisions on coverage determinations. This is a dynamic work environment and requires flexibility to meet business needs and adaptability to frequent changes. Teamwork is the norm and all employees will be held accountable to work as effective team members.
This position is for a Clinical Pharmacist working in the Prior Authorization unit within Customer Service department of OptumRx, a UnitedHealth Group company.
This is a call center based business segment and strict work guidelines are employed.
Reviewing Prior Authorization cases and rendering coverage determinations based on clinical criteria and plan design in a fast paced and dynamic environment
Work is computer based and may include receiving phone calls from Prior Authorization Pharmacy Technicians and/or providers where clinical information is involved
Role may include consulting physicians / providers with questions and interpretations of clinical guideline criteria and coverage determinations that have been rendered
Role may include participating in quality improvement and process enhancement projects as assigned by management
Role may include consulting with PA technicians and / or physicians regarding use of medications and advise of appropriate formulary alternatives when requested
Dedication to build rapport with coworkers, internal customers, and other departments by demonstrating a strong customer service orientation and a continuous positive image of OptumRx
Demonstrate ability to maintain productive working relationships with team members, other internal and external customers, and management team
Perform other duties as required
BS in Pharmacy or Pharm D degree
Pharmacist license in good standing in the State of California
Strong drug product and clinical pharmacy knowledge
Computer and typing proficiency is required, including MS Word
Excellent written and oral communication skills
Excellent interpersonal and problem-solving skills
Strong customer service orientation and commitment to professionalism
Demonstrated ability to work independently with minimal supervision
Ability to work (an 8-hour shift) within the hours of 9:00am to 7:00pm Monday - Friday, including Saturdays and/or Sundays by rotation
Ability to work overtime based on the needs of the business
1 years of practicing Pharmacist experience
1 years of Pharmacist experience working in a clinical pharmacy practice setting
Pharm D degree and completion of Pharmacy Residency
Experience developing or operationalizing medication clinical guidelines and/or formulary development
Experience working with a PBM company or managed healthcare system
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: Clinical Pharmacist, Prior Authorization, Appeals, Pharmacist, Registered Pharmacist, PharmD, Pharm D, Costa Mesa, CA, California
Unitedhealth Group Inc.