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Utilization Management Pharmacist

2 months ago

Las Vegas, United States UnitedHealth Group Full time

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Under minimal supervision, the Clinical Pharmacist, Utilization Management (UM) for WA, OR, CO, NV, UT, AZ, or NM is responsible for completing prior authorization functions as needed for value-based patients in the Optum West region. The programs involve interaction with utilization management team members, physicians, nurses, and other health care providers to provide information and education about the utilization of medications. The Pharmacist, Utilization Management is also responsible for following processes to improve patient care, outcomes, and regulatory requirements.

The Clinical Pharmacist, Utilization Management, is responsible to collaborate with health care teams to evaluate medication utilization and prior authorization requests as it relates to benefits, medical necessity, affordability, site of service and patient efficacy. Provide up-to-date drug information to health care providers in the medical offices and provide feedback regarding cost-effective prescribing. Assist other care lanes to develop and manage medication programs for appropriate utilization and medication safety. The Clinical Pharmacist, Utilization Management will accurately and timely perform delegated clinical determinations for professionally administered medications. The duties listed below are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment.

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

Primary Responsibilities:

  • 90% Clinical Pharmacy Utilization Management

  • Collaborates with the Pharmacy and Regional Leadership to effectively implement, evaluate and optimize national, regional, and local pharmacy & medication utilization initiatives related to clinical pharmacy and health plan coverage

  • Provide timely review for value-based patients by processing prior authorization and medical necessity requests for specialty ambulatory injectable and/or infusion medications

  • Assists with alternate sites of services for medications as needed

  • Review specialty medication prior authorization requests (i.e., biopharmaceuticals) according to established treatment protocols, clinical criteria, and member benefits

  • Make authorization determinations within the defined turnaround times and meet regulatory requirements

  • Participate in ongoing reviews of medication policies and procedures, protocols, guidelines, and tools to improve utilization management

  • Assist with the development of resources to align various levels of clinical pharmacy services to local and regional medication utilization initiatives

  • Implement medication cost-effectiveness initiatives into pharmacy for high cost injectables (i.e., Part B, etc.) and ambulatory medication (i.e., Part D, etc.) for value-based patients to help reduce total cost of care

  • Participate in audit reviews to ensure compliance and standardization of documentation and citations

  • Utilize metrics and dashboards with key performance indicators to ensure optimal clinical pharmacy and medication outcomes

  • Participate in providing medication utilization feedback to providers and provider business managers using available data (i.e., prescriber profiles, dashboards, and academic detailing)

  • Communicate with requesting provider groups through electronic health records (i.e., Epic, etc.) and other electronic care systems and programs

  • Interface with health plans on drug related issues as needed

  • Knowledgeable of current and emerging oncology and non-oncology clinical trends

  • Active participation in various clinical and regional departmental meetings and forums to improve clinical programs, enhance processes, and share clinical information

  • Continuously look for ways to streamline and improve workflow

  • Serves as a clinical resource and consultant in all areas of pharmacy and medication management

  • Research drug information to maintain drug knowledge and disease state understanding for application to prior authorization reviews

  • Precept, train and/or mentor teammates, providers, interns, and pharmacy residents as needed

  • 10% Performs other duties as assigned

This is a full-time position with variable hours between 8:00 am to 7:00 pm PST, Monday - Friday (Five 8-hour days) - Rotating weekend coverage.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • PharmD

  • Current WA, OR, CO, NV, UT, AZ, or NM Pharmacist License, unrestricted

  • Willing to pursue licensure in additional states: WA, OR, CO, NV, UT, AZ, or NM

  • 3+ years clinical pharmacy and/or clinical health plan experience in working with physicians and other health care professionals

  • Proficient in Microsoft Office Suite - Outlook, Word, Excel

Preferred Qualifications:

  • AZ Unrestricted Pharmacist License

  • CO Unrestricted Pharmacist License

  • NM Unrestricted Pharmacist License

  • NV Unrestricted Pharmacist License

  • UT Unrestricted Pharmacist License

  • WA Unrestricted Pharmacist License

  • OR Unrestricted Pharmacist License

  • 1+ years experience in Oncology Setting

  • Knowledge and understanding of NCQA Guidelines

  • Knowledge of Medicare, Medicaid, and commercial payor guidelines

  • Knowledge clinical evidence resources for use in individual case research

  • Knowledge of Managed care concepts and utilization management principles

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for this role is $88,000 to $173,200 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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