Appeals Pharmacist - Cypress, CA or Sugarland, TX

You're looking for something bigger for your career. How about inventing the future of health care? OptumRx is creating an innovative approach to Pharmacy Benefit Management. Here you'll find a professional culture where you can use your talent and our resources to make an impact on a huge scale. With better schedules than retail and more reach than any hospital, you'll open doors for yourself that simply do not exist in any other organization, anywhere. Take this opportunity to start doing your life's best work.(sm) 
  
Appeals pharmacist will work researching, evaluating, and making determinations on member and provider appeals of pharmacy coverage decisions. Excellent clinical skills required. The job requires the ability to gather complex clinical information, coverage policy and criteria information and work within regulatory guidelines to make coverage recommendations. Position requires excellent record keeping skills as well as excellent written communications skills. 
 
Primary Responsibilities:

Evaluate prescriptions and patient histories 
Interpret physicians' prescriptions and clinical documentation, accesses clinical criteria and compendia support 
Consult with customers, patients and/or physicians regarding use of medications, potential drug interactions, and clinical status for appeals requests 
Conduct Quality Assurance and verify the accuracy of all prescriptions to render appeal decision 
Provide explanations and interpretations within area of expertise 
Review formulary and utilization management guidelines to determine if the drug should be a covered benefit for the beneficiary based on their medical history
Research, evaluate, and make determinations on member and provider appeals of pharmacy coverage decisions
Gather complex clinical information, consider approved compendia, medical literature, coverage policy, and criteria information and work within regulatory guidelines to render decisions. Decision may require consulting with Plan Medical Directors and the beneficiaries treating physician.
Answer questions from support personnel regarding prescription drugs
Position requires excellent record keeping skills, thorough documentation, clear and concise written/verbal communications skills.
Please note: This position requires a rotating 8 hour shift between the hours of 6 am – 7 pm PST (Pacific Standard Time) if in Cypress, CA or CST (Central Standard Time) if in Sugarland, TX. This position also requires a rotating Saturday schedule as well as Sunday coverage when overtime is required.  

Required Qualifications:

Active, unrestricted Pharmacist license  
Minimum 1 year of experience working as a pharmacist
Must be able to work the designated shift (if needed) and flexibility with schedule based on department needs.
Excellent written and verbal communication skills
Experience using online clinical references and accessing professional (clinical and regulatory) internet sites 
Experience working with onscreen document images 
Intermediate computer proficiency with MS Office and must have the ability to navigate a Windows based environment
Preferred Qualifications:

Pharmacy Residency experience is a plus 
PBM experience
Pharm D
Experience in Medicaid, Commercial (private), and/or Medicare Part D prescription drug plans, programs or formularies
Experience in Coverage Determinations (prior authorization) or member appeals
Pharmacy reimbursement (third party insurance, Medicare Part D formulary management, Medicaid)
Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can do your life's best work.(sm)
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.
 
Job Keywords: Appeals Pharmacist, Clinical Pharmacist, Medicare, Managed Care, Pharmacy Reimbursement, Medicare Part D, Cypress, CA, California, Sugar land, TX, Texas