Supervisor for Pharmacy Claims Prior Authorizations and Appeals - National Remote

Company: UnitedHealth Group
Location: Orlando
Posted on: March 20, 2023

Job Description:

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

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Supervisor for Pharmacy Claims Prior Authorizations and Appeals -will be responsible for supervision of access and reimbursement specialist team within the Optum Frontier portfolio. The supervisor will have direct oversight of team members that may work onsite or remotely across the country. Under direct supervision from the Pharmacy Manager of PA's and Appeal, the Supervisor will be responsible for direct oversight of the team of specialists. This specialized team is responsible for the initiation and ongoing follow up of all prior authorization, financial assistance and appeals processes. The team triages prescriptions and medical orders to participating pharmacies and providers once all coverage obstacles have been resolved. This position requires a leader that can accurately provide directions, teach researching techniques, address and communicate medical and prescription insurance coverage requirements as well as a comprehensive knowledge of Medicare, Medicaid and commercial plan structures and standards.This position will provide coaching, mentoring, and support in the development of staff and recognize individual and team success that result in a high-level of team engagement and commitment. - -

This position is full-time (40 hours/week) Monday to Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 09:00am - 05:00pm EST. It may be necessary, given the business need, to work occasional weekends and overtime. -

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

Primary Responsibilities: -

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• Work directly with leadership on recommended staffing needs using time studies and workforce management tools -
  
• Focus on employee development and coaching continuously to include monthly one-on-ones and interim and annual reviews -
  
• Manage employee schedules ensuring fair and consistent practices -
  
• Ensure policies and procedures are being followed. Become a subject matter expert on all workflow and policies to inform of work instruction and job aid content needs. -
  
• Work directly with training team to ensure all team members are trained to policies and procedures and work instructions. -
  
• Ensure team members remain compliant with all necessary licensure and continuing education requirements -
  
• Maintain close relationship with peer supervisors to ensure client needs are always exceeded -
  
• Navigate a highly matrixed organization using strong relationship building skills and clear communication in both verbal and written form -
  
• Drive understanding of systems to partner with leadership on implementation teams to be a subject matter expert in capabilities with understanding to inform on gaps and provide optionality for forward planning of successful implementations -
  
• Develop metrics for self and direct reports that align to the overall objective for the business -
  
• Ensure performance is tracked accurately utilizing internal tools and processes. -
  
• Participate and lead monthly meetings - -
  
• Provide recommendations to IT partners on system enhancements to better drive performance and quality - -
  
• Willingness to jump in and be an operator to ensure patients' needs are met -
  
• Maintains a working knowledge of program guidelines, FAQ's, products, and therapeutic areas related to assigned programs. -
  
• Responsible for reviewing,---interpreting, and reacting to data provided by clients and customers. -
  
• Knowledgeable and proficient in the entire prior authorization and appeals process for prescriptions medications, infusions, medical procedures, and devices. -
  
• Keeps current with existing treatment trends, treatment standards and updated indications related to assigned programs to complete pharmacy PA and Appeal forms and to write letters of medical necessity when applicable. -
  
• Knowledgeable and proficient in Coding principles, including CPT and HCPCS - - -
  
• Knowledgeable and proficient in Medical and pharmacy benefit structure of all major payer types including Medicare, Medicaid, and private commercial -
  
• Knowledgeable and proficient in Claims billing procedures of key payers as defined by plan -
  
• Keeps current with the requirements and eligibility criteria for copay assistance from public, private and non-profit organizations related to assigned programs in order to assist customers with enrolling into third party financial assistance opportunities when applicable. - -
  
• Coordinates the triage of patient, prescription and/or medical orders to the appropriate partner for fulfillment or administration. -
  
• Coordinates with board licensed healthcare professionals including but not limited to nurses, pharmacists, or supervised pharmacy interns for information needed to complete Prior Authorizations, Appeals and third-party financial assistance forms. -
  
• Follows up with pharmacy plans, medical plans and third-party financial assistance organizations for general information, status updates and determination details within specified timeframes. -
  
• Effectively explains approval or denial details with customers in a manner that is easily understood to fit the needs of the intended audience. - -
  
• Completes test claims or electronic verification of benefits when applicable. -
  
• Maintains company, employee, and customer confidentiality as well as compliance with all HIPAA regulations. -
  
• Accurately documents all customer communications in an appropriate and professional manner within specified timeframes. -
  
• Communicates customer statuses to the appropriate parties at specified intervals or as needed. -
  
• Resolves customer issues through basic troubleshooting and escalates potential problems or issues that require management's attention in a timely manner. -
  
• Completes all the duties associated to the Enrollment and/or Eligibility Specialist role when applicable or as assigned. -
  
• Accurately collect the information required for each program and capture the information in a Customer Relationship Management system (CRM) or database. -
  
• Recruit and hire employees to support the organizational structure of site to include onsite employees, telecommute, and remote workforce -
  
  
  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:
  
  
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  • High school diploma / GED (or higher)
    
  • 2+ years of hands-on Pharmacy Claims Processing, Benefit Verification or Prior Authorization processing experience with a hospital, medical or health service provider, PBM or payor - -
    
  • 2+ years of hands-on Pharmacy Claims Processing, Benefit Verification or Prior Authorization processing experience
    
  • Has been in a supervisory or lead role for 3 years -
    
  • Specialty Pharmacy experience -
    
    
    Telecommuting Requirements:
    
    
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    • Required to have a dedicated work area established that is separated from other living areas and provides information privacy
      
    • Ability to keep all company sensitive documents secure (if applicable)
      
    • Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
      
      
      Preferred Qualifications: -
      
      
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      • Associate's degree, -Medical Certification or equivalent -
        
      • Valid license, registration and/or certification, in good standing, to practice as a Pharmacy Technician as required by the Board of Pharmacy in the state employed -
        
      • Pharmacy Accreditation experience -
        
      • Medical Billing/Coding experience -
        
      • Previous work history working in a matrixed environment, call center, operations environment -
        
        
        Soft Skills:
        
        
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        • Demonstrated ability to provide quality customer service -
          
        • Strong knowledge of Internet navigation and research -
          
        • Willingness to learn and grow in the position -
          
        • Participate in continuous quality improvement activities -
          
        • Be a team player and collaborate across functions -
          
        • Proven ability to set priorities and manage team to meet key objectives of the business -
          
        • Ability to manage more than one project or task at a time - -
          
        • Meet deadlines and proactively communicates roadblocks -
          
        • Speak, listen, and write in a clear, thorough, and timely manner using appropriate and effective communication tools and techniques -
          
        • Strive for thoroughness and accuracy when completing tasks -
          
        • Ability to work independently - -
          
          
          Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.
          
          California, Colorado, Connecticut, Nevada, Washington or New York, Rhode Island Residents Only: The salary range for California / Colorado / Connecticut / Nevada / Washington / New York / Rhode Island residents is $67,800 - $133,100.Pay is based on several factors including but not limited to education, work experience, certifications, etc. 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.
          
          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: 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.
          
          #RPO #YELLOW

Keywords: UnitedHealth Group, Orlando , Supervisor for Pharmacy Claims Prior Authorizations and Appeals - National Remote, Healthcare , Orlando, Florida