Columbus, Ohio
Denver, Colorado
Tyler, Texas
Wilmington, Delaware
Harrisburg, Pennsylvania
Posted: 27-Nov-24
Location: El Segundo, California
Categories:
Internal Number: 144765217
For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.
The Optum West UM Pharmacy Coordinator will collaborate with members, providers, and an interdisciplinary team focused on assuring safe and appropriate utilization of professionally administered medications. This role supports the UM pharmacist in providing urgent and routinely requested medication determinations in a time sensitive manner to help facilitate professionally administered medication treatments for Optum delegated members.
If you are located in the state of California, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
- Consults with and coordinates initial set up of and on-going requests for medication prior authorization, scheduling Pharmacist consultation meetings, and documenting outcomes in a professional manner
- Communicates directly with providers/designees when appropriate to gather all clinical information to assist in determination of the medical necessity of requested healthcare services and refers to appropriate staff for higher level of review when indicated
- Prepares utilization reviews of professionally administered medications using criteria and verifies benefits for services using health plan benefits and coverage
- Manages and follows relevant time limit standards necessary for conducting and communicating utilization review determinations in collaboration with UM pharmacists
- Prepares for oversight audits by the health plans and responds to documentation requests as directed
- Follow up with ancillary contracted entities if services or resources have not been made available to the member to assure that pharmaceutical needs are being met
- Reviews written requests for clinical services for necessary documentation and forwards to Utilization Management Pharmacist or Medical Director when necessary
- Interfaces with referring practitioners or staff, to facilitate prescribing of pharmaceutical alternatives within
specified time restrictions - Participates in process improvement projects and team meetings as required
- Responds to questions from medical offices, hospitals, and members about the necessary steps of the medical and pharmaceutical referral authorization processes and medication copay assistance alternatives
- Assists with preparation of utilization review authorizations, both verbal and written to assure high continuity of care for all managed care members in the program and consistency of gathering specific information within the department to comply with policies and procedures
- Works closely with members, member’s family, and interdisciplinary team to ensure proper information is disseminated to all stakeholders in a compliant fashion
- Works closely with the UM Clinical Pharmacy Manager to obtain timely decisions on pended referrals and requests for medical services from health plans and providers as needed
- Other duties as assigned
Positions in this function consult with customers, members, patients, providers, internal departments and/or external third parties on any or all of the following:- Consult with and coordinate initial set up and on-going treatment plan for specialty drug patients, including DURs, co-pay assistance, ancillary products, scheduling Pharmacist consults and/or RN visits, and liaison with provider offices on labs, refill orders and prior authorizations.
- Review and advise on medications and treatment plans (based on review of medical case notes, medication list and lab results) to improve outcomes and avoid potential drug interactions
- Discuss with patients life issues affecting medication adherence and provide advice on improving drug regimen compliance
- Advise patients on alternate Rx fill strategies of retail versus mail order and options for financial assistance
- May outreach to providers on suspected medication abuse situations
- Review medication regimen for disease state for LTC facilities/ hospice care / RN case managers / Medical Directors / clients and provide summaries and guidance on future medication plans. Advice may include alternate drug therapies, stopping a medication and/or lower cost alternative
- Review medical case notes to determine on-going medication treatment plan and project future medication costs
- Extensive work experience, possibly in multiple functions
- Work does not usually require established procedures
- Works independently
- Mentors others
- Acts as a resource for others
- Coordinates others' activities
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- High school education or equivalent experience
- Knowledge of advanced clinical standards, practices, and procedures for designated member population
- Knowledge of Medicare, Medicaid, and commercial payor guidelines
- Knowledge of, and skill in, the use of personal computer and Microsoft Office Suite
- Solid knowledge of pharmacy and medical terminology
- Proven solid customer Service, interpersonal and problem-solving skills
- Proven solid and clear verbal and written communication
- Proven solid attention to detail and ability to work efficiently using job aids for multiple platforms
- Proven ability to maintain positive teamwork attitude and professional demeanor at all times
- Proven ability to work cohesively with team, members, physicians, and medical staff
- Proven ability to plan, prioritize, and organize projects to meet established objectives of the team
Preferred Qualifications:
- California Pharmacy technician training /license
- 2+ years of experience in a clinical healthcare setting as Pharmacy Tech or Medical Assistant
- 2+ years of experience within Utilization Review function
- Prior Authorization experience in a pharmacy setting
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
California Residents Only: The hourly range for this role is $19.47 to $38.08 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
Diversity creates a healthier atmosphere: OptumCare 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
