Clinical Adjudication Manager Jobs (NOW HIRING)

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.

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

Primary Responsibilities:

• Serve as the clinical lead for utilization management coding, claim adjudication strategy, and system configuration activities, translating clinical policy intent, formulary strategy, and P&T decisions into operational requirements, RxClaim coding specifications, business rules, and automated decision logic
• Partner with technology, product, claims, coding, and operations teams to design, implement, test, and optimize adjudication logic, ensuring accurate execution of clinical programs, regulatory compliance, operational efficiency, and a seamless provider and member experience
• Act as the primary clinical liaison between business, product, technology, and operational stakeholders, ensuring alignment between clinical strategy, system functionality, adjudication outcomes, and organizational objectives
• Apply strong clinical knowledge of therapeutics and evidence-based medicine to evaluate medical literature, clinical guidelines, and healthcare trends, contributing to the development of drug coverage policies
• Presentation of utilization management criteria to committees such as the National Pharmacy & Therapeutics (P&T) committee and Utilization Management Committee
• Uphold high standards of clinical integrity and ethical practice to ensure fair and equitable access to medications through utilization management strategies
• Apply advanced therapeutic expertise to evaluate medical literature, clinical practice guidelines, pipeline therapies, competitive intelligence, regulatory requirements, and market trends to support development and maintenance of utilization management programs and coverage criteria
• Develop and present clinical analyses, recommendations, and utilization management strategies to Pharmacy & Therapeutics Committees, senior leadership, product teams, and other key stakeholders
• Partner with Drug Intelligence, Pipeline, Industry Relations, Formulary Strategy, and Clinical Utilization Management teams to evaluate emerging therapies and develop innovative coverage and management strategies, ensuring the strategies are coded accurately

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 or BS in Pharmacy
• Current pharmacist license in good standing
• Managed Care, PBM, health plan, or utilization management experience
• Experience working with RxClaims configuration, claim adjudication logic, and/ or utilization management coding activities
• Experience supporting clinical policy development, utilization management programs, or formulary management
• Experience collaborating across clinical, operational, technical, and business teams
• Demonstrated ability to analyze complex clinical and operational issues and develop practical solutions
• Demonstrated solid written and verbal communication skills with proficiency in Microsoft Office applications
• Demonstrated solid organizational skills with the ability to manage multiple priorities and competing deadlines

Preferred Qualifications:

• Completion of an accredited pharmacy residency or other advanced clinical training
• Residency training or other advanced clinical experience
• Experience developing coverage policies for drug coverage programs
• Experience participating in large-scale cross-functional projects involving product, technology, analytics, or operations teams
• Experience supporting AI, automation, or digital transformation initiatives within healthcare or pharmacy benefit management environments

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

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $91,700 - $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.

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.