Optum Utilization Review Jobs in Texas (NOW HIRING)

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40 locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.  

This position is responsible for performing and/or supervising clinical pharmacist activities related to Pharmacy Quality Initiatives (i.e. MTMP, Adherence, CPAS, vHTN, ePA, etc.) for Kelsey-Seybold Clinic and/or KelseyCare Advantage. The clinical pharmacist works collaboratively with healthcare providers to ensure patients are receiving the proper medications and dosages for the patient's condition. The clinical pharmacist performs medication reconciliation, counsels patients on medications & chronic disease states, conducts thorough chart reviews, addresses medication-related problems, develops effective medication plans & follow-up coordination, and documents accurately within the electronic medical records. The clinical pharmacist is responsible for the comprehensive understanding of program protocols, current clinical guidelines, and medication administration expertise in various populations; as well as, responsible for utilizing excellent communication skills, achievement of customer service objectives, compliance to organizational policies & procedures, and adherence to professional practices.

Primary Responsibilities:

• Responsible for conducting clinical pharmacy services through Pharmacy Quality Initiative Programs. During these encounters with members the following will be conducted: review of all current medications, review pharmacy claims in contracted PBM systems, drug-drug interactions screened, therapeutic alternatives recognized, communication with physician regarding drug therapy, patient counseling, medication reconciliation within EPIC (medical chart) and follow-up with member
• Answer inbound calls and conduct outbound calls regarding processing of coverage determinations. Review medical information essential for coverage determination to be conducted. Properly enters data into software program(s). Enter overrides in appropriate systems to process payment. Generates letters and/or reports
• Works all appropriate program workflow steps and queues as assigned. After hours/weekend coverage as assigned
• Communicate with physicians and other healthcare personnel to discuss specific medication recommendations, therapies for cost-effective care, general drug information, and educate about health plan prescription drug benefits
• Monitors and evaluated claims for appropriate use by members, physicians and pharmacies. Conducts drug utilization review of potentially fraudulent claims, abuse, and/or waste. Assists in reviewing claims adjudicated by the PBM to ensure payment for formulary products are processed correctly. Perform audits. Reports risks to management
• Communicates instructions to internal and external individuals and/or departments. Furnishes and obtains information from other entities/vendors. Maintains staffing and program schedules
• Assists in the development of clinical pharmacy program enhancement and better practices within the department including but not limited to RX Quality Initiative (RXQI), Pharmacy Quality Initiative Programs (QIP), Adherence Programs, Medication Therapy Management Program (MTMP), Hospital Discharge Program (HDP), Centralized Pharmacy Anticoagulation Service (CPAS), Fraud Waste and Abuse (FWA) protocols, and Coverage Determination (CD) processes
• Provide program training and oversight. Provide training and oversight of program staff, pharmacy residents and assigned interns as needed. Assists in scheduling of Health Plan Pharmacy Services Department personnel to ensure program productivity. Monitor daily duties and program work queues to ensure program requirements and department goals are achieved. Create program reports weekly, monthly, quarterly, annually or upon request from management. Communicate program and staff concerns to management
• Provides clerical support for Part D duties and audits. Provides administrative and clinical support for special projects. Responsibilities include attending and scheduling meetings, calendar management, dictation, answering phones and routine questions
• Ensures prompt and courteous customer service by all Health Plan Pharmacy Services personnel. Responsible for compliance to federal and state Pharmacy laws. Triages patient emergencies and other 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:

• Pharm D. degree
• Current and active Pharmacy License and Texas State Board of Pharmacy (TSBP)
• Registered Pharmacist
• Customer Service experience
• Proficient in alpha/numeric data entry with minimal errors
• Demonstrates strong multitasking, problem solving & analytical skills
• Proficient with computer applications that include, but are not limited to Microsoft Word, Excel, and Access
• Ability to lead others on team
• Detail oriented with good verbal and written communication skills, interpersonal skills, professional appearance, and ability to work effectively in a fast-paced work environment. Ability to communicate with all levels of the Management
• Excellent organizational skills
• High stress tolerance

Preferred Qualifications:

• Completion of a Managed Care Pharmacy Residency Program or Pharmacy Practice Residency Program (PGY1)
• ASHP Immunization Certification
• BLS Certification
• 1 years of retail, HMO 3rd party managed care
• Medicare Part D experience
• Customer Service experience
• Auditing experience
• Supervisory or management experience

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.

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

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.

OptumCare 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.

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