Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life’s best work.SM 

The Senior Pharmacy Care Coordinator will be responsible for the initiation and ongoing follow up of all prior authorization, financial assistance and appeals processes within the Optum Frontier portfolio. Under direct supervision from the Access & Reimbursement Supervisor, the Specialist triages prescriptions, and medical orders to participating pharmacies and providers once all coverage obstacles have been resolved. This position relies heavily on the ability to accurately follow directions, thoroughly research, address and communicate medical and prescription insurance coverage requirements as well as a comprehensive knowledge of Medicare, Medicaid and commercial plan structures and standards.

Hours: Monday-Friday, 10:00AM-6:30 PM EST

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. 

Primary Responsibilities:

• Responsible for reviewing, interpreting and reacting to data provided by clients and customers
• Maintains a working knowledge of program guidelines, FAQ’s, products and therapeutic areas related to assigned programs
• Knowledgeable and proficient in pharmacy and medical benefit structure of all major payer types including Medicare, Medicaid, and private commercial
• Be knowledgeable and proficient in the entire prior authorization and appeals process for prescriptions medications, infusions, medical procedures and devices
• Navigate calls to pharmacy benefit manager and medical plans to determine and obtain patient benefit structure details, initiate overrides, obtain contracting requirements, and initiate Letter of Agreement if necessary
• Follows up with pharmacy plans, medical plans and third-party financial assistance organizations for general information, status updates and determination details within specified timeframes
• Keeps current with existing treatment trends, treatment standards and updated indications related to assigned programs to complete Prior Authorization, Appeal forms, and to write letters of medical necessity when applicable
• Effectively explains prior authorization and appeal approval or denial details with customers in a manner that is easily understood to fit the needs of the intended audience
• Knowledgeable and proficient in Coding principles, including CPT and HCPCS
• Knowledgeable and proficient in Claims billing procedures of key payers as defined by plan
• Coordinates with board licensed healthcare professionals including but not limited to nurses, pharmacists, or supervised pharmacy interns for information needed to complete Prior Authorizations, Appeals and third-party financial assistance forms
• Keeps current with the requirements and eligibility criteria for copay assistance from public, private and non-profit organizations related to assigned programs to assist customers with enrolling into third party financial assistance opportunities when applicable
• Coordinates the triage of patient, prescription and/or medical orders to the appropriate partner for fulfillment or administration
• Completes test claims or electronic verification of benefits when applicable
• Assists with researching foundations available to support the patients' holistic needs
• Accurately documents all customer communications in an appropriate and professional manner within specified timeframes
• Communicates customer statuses to the appropriate parties at specified intervals or as needed
• Resolve customer issues through basic troubleshooting and escalate potential problems or issues that require management’s attention in a timely manner
• Maintains company, employee and customer confidentiality as well as compliance with all HIPAA regulations
• Completes all the duties associated with the Enrollment and/or Eligibility Specialist role when applicable or as assigned
• Accurately collect the information required for each program and capture the information in a Customer Relationship Management system (CRM) or database
• Provide recommendations to IT partners on system enhancements to better drive performance and quality
• Completes special duties or projects as assigned by the Program Manager / Supervisor

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 Diploma/GED (or higher) OR 5+ years of work experience in a Pharmacy related setting
• 2+ years of hands-on Pharmacy Claims Processing, Benefit Verification or Prior Authorization processing, or Medical Billing/Coding experience with a hospital, medical or health service provider, PBM or payor

Preferred Qualifications:

• Pharmacy Technician license in state of residence

Soft Skills:

• Demonstrated ability to provide quality customer service
• Ability to manage more than one project or task at a time
• Meet deadlines and proactively communicates roadblocks
• Speak, listen and write in a clear, thorough and timely manner using appropriate and effective communication tools and techniques
• Strive for thoroughness and accuracy when completing tasks
• Ability to work independently
• Strong knowledge of Internet navigation and research
• Willingness to learn and grow in the position
• Participate in continuous quality improvement activities
• Be a team player and collaborate across functions

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges. 

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy. 

California, Colorado, Connecticut, Nevada, New York City, or Washington Residents Only: The hourly range for California, Colorado, Connecticut, Nevada, Washington or New York City residents is $18.80 to $36.78. Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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: 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. 

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