This position is for a Clinical Nurse working in the Prior Authorization and Appeals unit of OptumRx, a UnitedHealth Group company. This is a call center based business segment and strict work guidelines are employed. The nurse’s primary role is reviewing Prior Authorization and Appeals cases and rendering coverage determinations based on clinical criteria and plan design in a fast paced and dynamic environment.
· Work is computer based and includes receiving phone calls from prior authorization pharmacy technicians and/or providers for clinical information
· Consult physicians/providers with questions, interpret clinical guideline criteria, and render/review coverage determination for prior authorization cases
· Consult with pharmacy technicians and/or physicians regarding use of medications and advise of appropriate formulary alternatives when requested.
· Gather complex clinical information, coverage policy and criteria information and work within regulatory guidelines to make coverage determinations
· Organize workload, set priorities, complete assignments in a timely manner and utilize resources appropriately while complying with department program standards
· Perform all duties and functions in compliance with state and federal pharmacy laws and regulations
· Conform with and supports department quality assurance and improvement guidelines
· 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.