Pharmacy Utilization RN - CA Remote

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.

Unique opportunity for a UM Nurse to improve patient care and outcomes through completion of utilization management functions for value-based patients in the Optum West region (CA).

This is a full-time position with variable hours between 7:00 am to 7:00 pm PST, Monday - Friday (Five 8-hour days). Rotating weekend coverage. 100% telecommuter position.

Under general supervision of the Pharmacy Manager, the RN is responsible for utilization review and the coordination of members Medicare Part B, Commercial, Medicaid medication through UM Pharmacy staff, Medical Directors and various other departments. This position will perform reviews of specialty drugs appropriateness as applicable to Medicare Part B, Commercial, Medicaid benefit.

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

Primary Responsibilities:

• Provide summary clinical and ancillary information to Pharmacist, Medical Director for review and decision making for targeted Medicare Part B, Commercial, Medicaid medications
• Discuss patient care specifics with peers or providers involved in overall patient care and benefits
• Advocate to pharmacists and others for appropriate decisions (e.g., patient level of care changes) regarding patient health and welfare (e.g., care and service coverage, safety)
• Research and identify information needed to perform assessment, respond to questions, or make recommendations (e.g., navigate knowledge Library resources, and websites and databases such as MicroMedex and National Comprehensive Cancer Network)
• Answer members and providers questions regarding care (e.g., medication, treatment) and benefits
• Apply knowledge of pharmacological and clinical treatment protocol to determine appropriateness of care and treatment requested
• Demonstrate understanding necessary to assess, review and apply criteria policy (e.g., Milliman guidelines, CMS criteria, medical policy, plan specific criteria)
• Demonstrate knowledge of process flow of UM including prior authorization, concurrent authorization and/or clinical appeal and grievance reviews
• Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives. Utilizes independent judgment in problem-solving by developing or adjusting processes and composing procedures
• Performs all other related duties as assigned

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:

• Graduation from an accredited school of nursing
• Active, unrestricted California Registered Nurse license
• 5+ years of clinical nursing experience
• 2+ years of experience in managed care, utilization review, case management
• Experience working in a metric-driven environment
• Medical terminology, ICD-9/ICD-10 and CPT knowledge
• Excellent written and verbal communication skills
• Solid analytical and PC operation skills including Microsoft Office applications

Preferred Qualifications:

• 2+ years of experience practicing as a bedside nurse in an acute care setting
• Experience with specialty medications such as Oncologic agents, Immunologic, or other specialty injectable highly desirable
• Relevant experience in UM process activities such as prior authorization or medical claims review
• Experience with Medicare guidelines

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

The salary range for this role is $59,500 to $116,600 annually based on full-time employment. 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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

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