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Pharmacy Oversight Coordinator - RN Preferred - Telecommute

UnitedHealth Group

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761155 Pharmacy Oversight Coordinator RN Preferred Telecommute

Pharmacy Oversight Coordinator - RN Preferred - Telecommute (761155)

Position Description

Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. Bring your skills and talents to a role where you'll have the opportunity to make an impact on a huge scale. This is the place to do your life's best work.(sm)


Responsible for telephonically managing the medication regimen for a claimant following an injury.  The Clinical Rx Oversight Coordinator monitors medical treatment and acts as a liaison between the account, and provider to monitor and aggressively manage the medication regimen in accordance with the ODG, formulary and FDA guidelines for cost effective outcomes.



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



Primary Responsibilities:

  • Implements and acknowledges all new referral contacts to account within same business day

  • Provides account with summary and action plan for managing medication regimen recommendations following a peer review and discussion within 48 hours of receipt of RX Oversight referral

  • Communicates verbally with the attending physician for information on the last and next visit dates and any updates on the medication regimen

  • Coordinates written/fax communications with the Attending Physician of record for an implementation plan on the agreed upon medication regimen changes

  • Coordinates Cognitive Behavioral Therapy and monitors program for efficacy in correlation to medication weaning process

  • Monitors all treatment and Rx transactions on a minimum of a monthly basis for adherence to the implementation plan. Risk manages any changes to the implementation plan in accordance with ODG, formulary and FDA guidelines

  • Evaluates Rx transaction history within Sequoia for refill patterns and any changes to plan

  • Secures, reviews and evaluates all medical correspondence obtained from providers for compliance and progression with the implementation plan, and timeframes for goals

  • Recognizes risk management opportunities to work with the physician for alternative Rx with same therapeutic value but more cost effective; evaluates Rx for brand to generic conversions; and assesses potential of duplication of medications prescribed, accessing internal pharmacist staff for expert opinion to communicate with the physician on basis of recommendations

  • Coordinates file reviews with the RMNRS Manager on all files for status updates on action plan progress to goal

  • Contacts accounts for directives and provides updates on file status on a regular basis, inclusive of after each office visit

  • Inputs notes on “all” tasks utilizing the RMS notepad for each file, and places all created, and received documents in the Admin tab for each file

  • Coordinates Pharmacy Expert Litigation reviews with internal Pharmacist for arbitration support on UCR review of non-compound retail charges to AWP, and as well clinical analysis of appropriateness of compound medications

  • Reviews Rx Prior Authorization (PA) requests from Cypress Care for relatedness to injury, and for compliance with formulary and plan guidelines

  • Provide written evaluation as to recommendation for Rx PA approval or exclusion from coverage to account for the adjuster to make the final determination on eligibility of coverage

  • Reviews medical bills for relatedness to injury and Medicare coverage (when applicable); then enters Treatment Plan for that bill in RMS and renders determination on approval or exclusion of coverage; then releases the bill to Bill Review Department electronic for processing of fee schedule application and advise to pay (EOR) to client

  • Reviews referrals/scripts for Specialty Services in accordance with relatedness to injury and Medicare coverage (when applicable); and coordinates referral with Cypress Care for fulfillment

  • Reviews referrals for Rx card services in accordance with plan eligibility per account, and coordinates referral to Cypress Care Pharmacy support to set up card services

  • Prepares all letters and sends to CMA for formatting and mailing

  • Updates accounts via emails and phone

  • Prepares medical cost projections for life expectancy claim costs; as well as analyses benefit outcomes and documents savings

  • Ensures confidentiality and maintains accurate record keeping

  • Attends in services and continuing education seminars as appropriate to renew licensure and meet Company requirement of 12 CEUs per year

  • Utilizes effective oral, written and organization skills and demonstrates the ability to prioritize case activities

  • Responsible for providing any changes to licensure immediately upon occurrence and notice from the State. (Renewal, Suspension, Termination,etc.)

  • Holds to the philosophy and standards of quality as outlined by Procura Management Inc.

  • Performs other case management duties as required

Required Qualifications:

  • 3 + years of related nursing case management experience
  • Clinical background with exposure to prescription medications
  • Valid RN or LPN license (LPN’s may be considered if preferred qualifications are met)
  • Experience working with electronic medical records and/or electronic claims systems
  • Intermediate to advanced skills in Microsoft Work and Outlook
  • Proficient skills in Microsoft Excel
  • Ability to work a consecutive 8 hour shift between the hours of 7am-7pm, Monday through Friday

Preferred Qualifications:

  • Clinical background with Prescription (Rx) management specific to opioids
  • Current and unrestricted RN license
  • Workers Compensation Case Management experience
  • Nursing experience in a hospital, clinic or physician’s office setting, providing direct patient care and administering medications
  • Previous experience working as a telecommuter
  • Bachelor’s Degree in Nursing

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)


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


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: Pharmacy, Coordinator, RN, LPN Case Management, Clinical, Remote, Telecommute, Telecommuter

Job Details

  • Contest Number761155
  • Job TitlePharmacy Oversight Coordinator - RN Preferred - Telecommute
  • Job FamilyNursing
  • Business SegmentOptumRx

Job Location Information

  • PA
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionYes
  • Overtime StatusExempt

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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