Pharmacy Care Coordinator

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 inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Hours/Location:  Must reside in Pacific or Mountain Time Zone. Variable hours to work 8-hours within the hours of 8:30 AM - 6:00 PM Pacific Standard Time Monday - Saturday based on business needs.  

These efforts collectively promote clinical efficacy, cost-efficiency, and improved patient outcomes. Broad-based and comprehensive knowledge is critical to success in this role. You'll need to be well-versed in medical and pharmacy claims data.

You'll enjoy the flexibility to work remotely * from anywhere within Pacific or Mountain Standard Time Zones in the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Medication Access: Support access to medications by evaluating benefit options following UM (utilization management) determinations, including coverage denials or redirections. The role involves structured investigations to determine coverage under both medical and pharmacy benefits according to payer guidelines and plan requirements. Key tasks include confirming patient insurance eligibility and evaluating coverage standards across different benefits. This process may require examining prior authorization requirements, formulary placement, site-of-care policies, and potential patient cost implications

• Care Coordination:  Work closely with physicians, advanced practice providers, nurses, pharmacists, and other healthcare professionals to promote coordinated care and effective medication management. The position requires proactive communication with other healthcare professional via phone, fax, and other electronic channels

• Cross-Functional Team Collaboration: Collaborate with various cross-functional teams to implement strategic projects that improve care delivery and network operations, ensuring compliance and maintaining high clinical standards. These teams span areas such as pharmacy management, utilization management, payment integrity, claims processing, health economics, finance, and contracting

• Compliance and Regulatory Requirements: Adhere to organizational policies related to affordability programs, patient confidentiality, and medication safety. Follows relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g., SOP's and Job Aids)

• Continuous Improvement: Engage in quality improvement activities and process enhancements aimed at increasing the efficiency and impact of affordability program

•  Additional Duties:

  • Applies a team approach to solve complex problems

  • Adapt team priorities to ensure task completion

  • Serves as a primary point of contact and provides explanations for members, providers, and internal partners regarding processes, roles and responsibilities within their department

  • Prepare medication utilization and prior authorization requests for specialty oncology and non-oncology ambulatory injectable and/or infusion medications as related to member benefits, health plan coverage, site of service, and evidence based clinical guidelines

  • Solves moderately complex problems and/or conducts moderately complex analyses and translates concepts into practice

  • Provides explanations and information to others on issues

  • Identifies incomplete/inconsistent information in medical records and label missing measures/metrics/concerns as well as evaluate documentation of prior authorization

  • Coordinates auditing tasks as assigned

  • Verifies necessary documentation is included in medical records

  • Develops learning objectives based on appropriate analyses (e.g., business analysis, task analysis, audie