About the Company
OptumRx, a part of Optum and UnitedHealth Group, is a leading pharmacy care services provider that is transforming the pharmacy experience. We simplify the pharmacy benefit for more than 65 million members and clients by managing pharmacy costs and improving health outcomes. Our innovative solutions and dedicated team are committed to making healthcare work better for everyone.
Job Description
We are seeking a dedicated and detail-oriented Remote Pharmacy Prior Auth Specialist with a strong focus on Payor Services to join our growing team. In this 100% remote role, you will be responsible for processing pharmacy prior authorization requests from healthcare providers, ensuring compliance with payor-specific criteria and clinical guidelines. You will collaborate closely with various stakeholders, including pharmacists, physicians, and health plan representatives, to facilitate timely and accurate resolution of prior authorization requests, ultimately supporting members’ access to necessary medications.
Key Responsibilities
- Process pharmacy prior authorization requests according to established policies, procedures, and payor-specific guidelines.
- Review clinical documentation provided by prescribers to determine medical necessity and adherence to coverage criteria.
- Communicate effectively with prescribers, pharmacies, and health plan members regarding prior authorization status and requirements.
- Accurately document all prior authorization activities and communications in the designated system.
- Identify and escalate complex or unresolved issues to senior specialists or pharmacists as appropriate.
- Maintain up-to-date knowledge of pharmacy regulations, payor policies, and clinical guidelines related to prior authorizations.
- Participate in quality assurance activities and process improvement initiatives.
- Adhere to all HIPAA regulations and ensure patient confidentiality at all times.
Required Skills
- High School Diploma or GED required.
- 3+ years of experience in pharmacy operations, medical office, or a healthcare customer service role.
- 1+ year of experience with pharmacy prior authorizations.
- Strong understanding of pharmacy terminology and medication classes.
- Excellent written and verbal communication skills.
- Proficiency in navigating multiple computer systems and databases simultaneously.
- Ability to work independently in a remote environment and manage time effectively.
- Exceptional attention to detail and organizational skills.
Preferred Qualifications
- Associate's or Bachelor's degree in a healthcare-related field.
- Certified Pharmacy Technician (CPhT) certification.
- Experience with various payor systems and prior authorization platforms.
- Knowledge of Medicare Part D and commercial insurance plans.
Perks & Benefits
- Comprehensive medical, dental, and vision insurance.
- 401(k) retirement plan with company match.
- Paid time off and company holidays.
- Tuition reimbursement program.
- Employee assistance program.
- Wellness programs and resources.
- Career development and growth opportunities within a large healthcare organization.
How to Apply
If you are interested in this position, please click the "Apply Now" button below. To ensure your application is properly considered, please prepare the following:
- An up-to-date Resume or CV
- A brief cover letter summarizing your experience and motivation
Applications are reviewed on a rolling basis. Only shortlisted candidates will be contacted for an interview.
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