Prior Authorization Pharmacist

About the position

The Clinical Pharmacist in Prior Authorization at OptumRx is responsible for reviewing prior authorization cases and making coverage determinations based on clinical criteria and plan design. This role operates in a fast-paced call center environment, requiring flexibility and adaptability to frequent changes. The position emphasizes patient safety and quality of work, with a focus on building rapport and maintaining productive relationships with coworkers and healthcare providers.

Responsibilities

• Review prior authorization cases and render coverage determinations based on clinical criteria and plan design.
• Gather complex clinical information and coverage policy while adhering to regulatory guidelines.
• Maintain minimum productivity and quality targets as dictated by the department's performance matrix.
• Receive phone calls from pharmacy technicians and providers for clinical information and consult with physicians/providers as needed.
• Ensure compliance with state and federal pharmacy laws and regulations.
• Build rapport and maintain productive working relationships with coworkers and management.
• Perform all duties in compliance with department program standards and safety protocols.
• Complete other duties and responsibilities as assigned by management.

Requirements

• Pharm.D. degree or Bachelor's degree in Pharmacy.
• Active and unrestricted Pharmacist license in good standing in the state of Vermont.
• Proven solid drug product and clinical pharmacy knowledge.
• Demonstrated ability to work independently with minimal supervision.
• Proven solid clinical ability to interpret criteria and implement clinical programs for prior authorization.
• Proven computer and typing proficiency, including Microsoft Excel, Word, Outlook, and SharePoint.

Nice-to-haves

• 1+ years of experience working as a clinical pharmacist.
• Experience working in Prior Authorization.
• Experience within a managed healthcare system.
• Proven working knowledge of Medicare Part D, CMS regulations, NCQA, and State regulations.

Benefits

• Paid Time Off (PTO) starting from the first pay period plus 8 Paid Holidays and a Floating Holiday.
• Medical Plan options with participation in a Health Spending Account or Health Saving Account.
• Dental, Vision, Life & AD&D Insurance, Short-term and Long-term Disability coverage.
• 401(k) Savings Plan and Employee Stock Purchase Plan.
• Education Reimbursement and Employee Discounts.
• Employee Assistance Program and Employee Referral Bonus Program.
• Voluntary Benefits including pet insurance, legal insurance, and LTC Insurance.