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in Irvine, CA

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Hours Full-time, Part-time
Location Irvine, CA
Irvine, California

About this job

Expanding access to affordable, high quality health care starts here. This is where some of the most innovative ideas in health care are created every day. This is where bold people with big ideas are writing the next chapter in health care. This is the place to do your life's best work.


The Senior Network Program Specialist will support Pharmacy Benefit Manager's (PBM) client base by ensuring pharmacy network compliance with regulatory requirements. Implement programs to manage federal and state regulations requirements.  Examples include provider relations activities, pharmacy compliance audits, analyzing provider performance and compliance with contractual and regulatory requirements and outreach to pharmacies to ensure compliance with regulations.

 

Position is responsible for the successful program operations and program/product implementation. Obtains data, verifies validity of data, and analyzes data as required. Analyzes pharmacy network availability and access to comply with federal and state regulations. May make recommendations regarding use, expansion, selection of networks and pharmacies for various products based on that analysis. Position supports pharmacy network compliance committee and managing programs and process required by applicable laws, regulations, and CMS guidance.  May develop compliance communications to providers and drive problem resolution within the department.

 

This position is responsible for day-to-day interaction with OptumRx's retail pharmacy partners, the person filling this role will be responsible for assisting with trouble-shooting claim processing issues submitted by our chain pharmacy partners on a regular basis; as such, retail pharmacy experience, experience with OptumRx's claims processing platform and knowledge of the retail pharmacy industry are strongly desired.

 

General Job Profile

In this role you will be expected to:

- Use pertinent data and facts to identify and solve a range of problems within area of expertise.

- Investigate non-standard requests and problems, with some assistance from others.

- Work exclusively within a specific knowledge area .

- Prioritize and organize own work to meet deadlines.

- Provide explanations and information to others on topics within area of expertise.

- Generally work is self-directed and not prescribed.

- Works with less structured, more complex issues.

- Serves as a resource to others.

Job Scope and Guidelines

- Assesses and interprets customer needs and requirements.

- Identifies solutions to non-standard requests and problems.

- Solves moderately complex problems and/or conducts moderately complex analyses.

- Works with minimal guidance; seeks guidance on only the most complex tasks.

- Translates concepts into practice.

- Provides explanations and information to others on difficult issues.

- Coaches, provides feedback, and guides others.

- Acts as a resource for others with less experience

 

** This role is based in either the Irvine, CA or Eden Prairie, MN offices **


 

Requirements

Requirements:
- Undergraduate degree.
- 3+ years experience with network data management 
- 1+ years experience in provider data analysis.
-  Intermediate experience with claims processing or resolution.
- 3+ years experience with medical coding preferred
- 1+ years experience implementing programs to manage federal and state regulations requirements to ensure compliance.
- Ability to convey complex information to others and make it more easily understood.
- Ability to prioritize multiple tasks in an environment of rapid change.
- Excellent phone presence and communication skills.
- Intermediate proficiency in MS Office (Excel, Word and PowerPoint).

Preferred Skills:
- 3+ years experience with claims processing systems and provider data bases, claims system testing experience preferred.
- Project management experience a plus.


- Knowledge of the retail pharmacy industry are strongly desired.


 
Careers with OptumRx. We're one of the largest and most innovative pharmacy benefits managers in the US, serving more than 12 million people nationwide. Here you'll fill far more than prescriptions. As a member of one of our pharmacy teams, you're empowered to be your best and do whatever it takes to help each customer. You'll find unrivaled support and training as well as a wealth of growth and development opportunities driven by your performance and limited only by your imagination. Join us. There's no better place to help people live healthier lives while doing your life's best work.SM

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.