Optum Appeals 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 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.

As a Prior Authorization Pharmacist, you will support clinical review, decisioning, and communication related to pharmacy prior authorization and appeals requests. This role requires strong clinical judgment, attention to detail, and the ability to apply benefit plan criteria, regulatory requirements, and established workflows to help ensure timely, accurate, and compliant determinations. You will collaborate with providers, members, internal teams, and leadership to resolve inquiries, support quality outcomes, and contribute to a service-focused pharmacy operations environment.

Work Schedule: 8-hour shift Monday - Friday between 8am - 8pm EST with rotating on-call weekend responsibilities on Saturdays or Sundays, overtime, & holidays (work schedule will vary based on business needs)

If you reside in the state of Vermont or Maine, you will have the flexibility to telecommute as you take on some tough challenges.

• Review, decision, and process prior authorization and appeals requests using established clinical criteria, benefit plan requirements, regulatory guidelines, and applicable client-specific instructions
• Navigate multiple computer systems, job aids, knowledge resources, and case-management tools to research medication information, verify benefit details, document actions, and support accurate case resolution
• Receive inbound calls from members, providers, pharmacies, or internal partners to clarify prior authorization requirements, request additional information, explain case status, or provide follow-up within role scope
• Apply clinical and benefit criteria to support approval, denial, recommendation, or escalation decisions, while clearly documenting the rationale and maintaining compliance with turnaround time, quality, and regulatory expectations
• Maintain a safe, secure, and compliant work environment by protecting systems, equipment, confidential information, and protected health information, and by promptly reporting any concerns to leadership

• Demonstrate strong attention to detail when reviewing clinical information, prescription details, diagnosis information, benefit criteria, and supporting documentation to ensure accurate and compliant case processing
• Accurately document call details, clinical findings, case actions, approvals, denials, transfers, escalations, outreach attempts, and follow-up activity in the appropriate systems
• Protect confidential information and handle protected health information in accordance with privacy, security, HIPAA, regulatory, and company requirements
• Use sound judgment to identify incomplete information, clinical uncertainty, workflow barriers, urgent concerns, or situations that require additional pharmacist review, leadership guidance, or escalation
• Adapt to changing workflows, client requirements, system updates, job aids, and business priorities while maintaining accuracy and service standards
• Perform other duties as assigned by management

Patient Safety & Quality Initiatives:

• Patient Safety and Quality of work is paramount and it's important for employees to have a safe and secure workspace and communicate with their leadership when that safety (equipment, system, information) is compromised
• Promote a culture of safety that is equitable, transparent, and engaging for patients, family caregivers, and healthcare workforce.
• Enhance workforce safety and well-being

What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical plan options along with participation in a Health Spending Account or Health Savings Account
• Dental, Vision, Life & AD&D Insurance, Short-Term Disability, and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
• More information can be downloaded at: http://uhg.hr/uhgbenefits

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.

• Bachelor of Pharmacy or Doctor of Pharmacy degree from an accredited pharmacy program and an active pharmacist license
• Current, unrestricted pharmacist license in the state of residence, with responsibility for maintaining licensure in good standing and meeting any applicable continuing education requirements
• Intermediate level of proficiency with Microsoft Excel, Word, Outlook, and Teams, including the ability to create, edit, save, send, organize, and manage basic documents, spreadsheets, emails, meetings, and communications
• Ability to work any assigned shift within the 8:00 AM to 8:00 PM operating window, including flexible hours, overtime, weekends, holidays, and on call responsibilities as required by business and patient/member needs
• Must reside in Maine or Vermont

• Experience working in a high-volume, production-based, quality-monitored, or compliance-driven environment
• Knowledge of Medicare Part D, commercial, Medicaid, exchange, or client-specific pharmacy benefit requirements
• Knowledge of call center systems such as CMS, IEX, CTI, TCS, or similar telephony, workforce, and case-management platforms
• Familiarity with pharmacy terminology, medication names, brand and generic drug names, SIG codes, benefit terminology, and healthcare documentation standards

• Strong verbal and written communication skills, with the ability to explain clinical, benefit, and case-related information clearly, professionally, and accurately to providers, members, pharmacists, leaders, and internal partners
• Strong attention to detail and ability to consistently apply clinical criteria, workflow instructions, documentation standards, privacy requirements, and quality expectations
• Ability to manage competing priorities, maintain productivity, follow through on assigned work, and meet service-level expectations in a fast-paced, metric-driven environment
• Ability to work efficiently across multiple systems, screens, job aids, knowledge articles, queues, and electronic workflows while maintaining accuracy during calls, clinical review, and case processing
• Critical thinking, problem-solving, and sound professional judgment to identify risks, incomplete information, potential compliance concerns, and cases requiring escalation or additional review
• Ability to receive feedback, adapt to coaching, adjust performance, and support continuous improvement in quality, productivity, service, compliance, and member/provider experience outcomes

• Reliable high-speed home internet access, with the ability to use a hard-wired ethernet connection when required
• Secure, private home workspace that supports protection of confidential information and compliance with company telecommuter, privacy, and security policies
• Intermediate comfort using a computer, including keyboard and mouse navigation, opening applications, switching between multiple systems and screens, and learning new tools or workflows

*All Telecommuters 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 hourly pay for this role will range from $44 - $79 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health