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Supervisor Pharmacy Ops, Prior Auth (Costa Mesa/OK City)

UnitedHealth Group

Costa Mesa, CA
Job Code:
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Supervisor Pharmacy Ops, Prior Auth (Costa Mesa/OK City)(Job Number:724986)

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)

What makes your pharmacy career greater with OptumRx? You'll work within an incredible team culture; a clinical and business collaboration that is learning and evolving every day.

To succeed in this position, a baseline understanding of Prior Authorization processes is needed. These functions include processing requests for insurance coverage of formulary and non-formulary drugs that reject at the dispensing pharmacy based on pre-determined plan criteria. Plan criteria are setup based on evidence based medicine and includes the exercise of appropriate clinical judgment. Reviewing adverse coverage determinations before final decisions are rendered and, as required by law, work in conjunction with Medical Directors to render final decisions on coverage determinations when needed. This is a dynamic work environment and requires flexibility to meet business needs and adaptability to frequent changes. Teamwork is the norm and all employees will be held accountable to work as effective team members.

This position is for a Clinical Pharmacist Supervisor working in the Prior Authorization unit within OptumRx, a UnitedHealth Group company.

Primary Responsibilities:

  • Supervising a team of clinical pharmacists within Prior Authorization who focus on the following subject areas:

    • crafting Prior Authorization related communication material with focus on all lines of business serviced by the department

    • implementing new programs for Prior Authorization department and adequately communicating those objectives to the staff

    • understanding and interpreting clinical criteria and working to create clinical decision trees into the Prior Authorization system

    • understanding and interpreting clinical criteria and working to create provider coverage determination forms

    • reviewing Prior Authorization cases and rendering coverage determinations based on clinical criteria and plan design in a fast paced and dynamic environment

    • Perform other duties and projects as required

  • Role may include participating in quality improvement and process enhancement projects as assigned by management

  • Dedication to build rapport with coworkers, internal customers, and other departments by demonstrating a strong customer service orientation and a continuous positive image of OptumRx

  • Demonstrate ability to maintain productive working relationships with team members, other internal and external customers, and management team

  • Ability to read, understand, and interpret regulatory guidance towards the implementation of Prior Authorization related regulatory projects

Job Pharmacy Operations
Primary Location US-CA-Costa Mesa
Other Location US-OK-Oklahoma City
Organization OptumRx Prior Auth & Appeals
Schedule Full-time
Number of Openings 1
Apply on the Company Site

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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