About the Company
Optum, a UnitedHealth Group company, is a leading information and technology-enabled health services business dedicated to helping make the health system work better for everyone. With a mission to improve population health and individual well-being, Optum provides advanced data analytics, technology, and health services to over 100 million people worldwide. We are committed to innovation, compassion, and transforming healthcare.
Job Description
As a Remote Pharmacy Prior Auth Specialist with a focus on Payor Services, you will play a critical role in ensuring members receive timely access to necessary medications. This position involves reviewing prescription requests against established clinical criteria and payor guidelines to determine authorization for coverage. You will communicate with prescribing physicians, pharmacies, and members to gather information, explain decisions, and facilitate approvals. Success in this role requires meticulous attention to detail, strong communication skills, and a deep understanding of pharmacy benefits and prior authorization processes. This is a 100% remote position, allowing you to work from the comfort of your home while contributing to a vital healthcare service.
Key Responsibilities
- Review and process prior authorization requests for pharmacy medications in accordance with established clinical guidelines and payor-specific criteria.
- Communicate with prescribing providers and their offices to obtain necessary clinical documentation and clarify medication details.
- Educate members, providers, and pharmacies on prior authorization requirements, status, and appeal processes.
- Accurately document all interactions and decisions within the designated systems.
- Identify and escalate complex cases or coverage issues to pharmacists or clinical teams as needed.
- Adhere to all HIPAA regulations and maintain strict confidentiality of patient information.
- Stay current with changes in medication formularies, clinical guidelines, and payor policies.
Required Skills
- High School Diploma or GED
- 1+ years of experience in a pharmacy setting (retail, hospital, PBM, or managed care)
- Strong understanding of prescription medications, medical terminology, and dosage calculations
- Proficiency with computer systems, including electronic health records and pharmacy software
- Excellent written and verbal communication skills
- Ability to work independently in a remote environment with minimal supervision
- Ability to maintain focus and attention to detail in a fast-paced environment
Preferred Qualifications
- Associate's or Bachelor's degree
- Certified Pharmacy Technician (CPhT) certification
- Experience with prior authorization processes or payor services
- Experience with specific PBM or managed care systems
- Knowledge of HIPAA, Medicare Part D, and other regulatory guidelines
Perks & Benefits
- Comprehensive health, dental, and vision insurance plans
- 401(k) retirement plan with company match
- Generous paid time off and holidays
- Tuition reimbursement and continuing education opportunities
- Employee assistance program
- Remote work flexibility and support
- Career development and growth opportunities within a Fortune 5 company
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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