Senior Clinical Consultant - 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.

Positions in this function manage and support ongoing relationships with clients. Build client relationships and serve as outward-facing primary point of contact for overall and day-to-day service delivery (e.g. claims issues, prior auth/appeal resolution, and program implementation/review) for pharmacy needs for large/complex account(s) or state Medicaid programs.

Support health plan, workers comp and other client sales and management with pharmacy value story, rationale for drug management strategies, and act as a conduit to pharmacy management.

Prepare and present reports on utilization of current program offerings and recommendations for strategies to manage utilization and ensure programs fit the population served. Represent client(s) internally and coordinate with other functions to implement client programs, complete system updates and projects, and address ongoing pharmacy service needs. May work closely with account management on renewals and upselling.

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

Primary Responsibilities:

• Receive and interpret custom UM (PA, Quantity Limits, Step Therapy) criteria from outside vendor. Translate criteria into UCMS system
• Will require knowledge of therapeutic classes, drug coding (GPI, NDC, Drug lists, etc), new product impacted, and maintaining criteria coding as new drugs or devices are added to the criteria or removing medications, as necessary
• Maintain exclusion lists (from other a review and coding perspective) and rationale that clinical team will utilize for every specific exclusion
• RxClaims coding experience and knowledge on problem solving with coding a custom formulary and custom rejections and solutions
• Experience in Microsoft office suite of products and data tools such a power BI
• Assist in resolving member escalations with Care Team, UM, Formulary, Appeal and Plan Design inquiries. And provide feedback to prevent future member escalations
• Engage with physicians and local wellness clinic on general strategy and specific member issues
• Lead in client and account team reporting from a clinical perspective
• Develop and communicate SOPs for UM programs and formulary strategies for operations (PA, appeals, customer services)
• Comprehends and effectively explains formulary and clinical program changes to clients
• Stays aware of and provides clinical market intelligence to clients
• Provides education for clients, pharmacists, members and physicians per contractual requirements
• Communicates drug information to clients and responds to plan-specific clinical inquiries
• Formulate and deliver client recommendations based on available data
• Identifies opportunities for clinical program up-sell
• Makes clinically sound recommendations to clients based on trend
• Routinely collaborating with account management to provide clinical aspects of client quarterly reviews
• Able to incorporate treatment & practice guidelines into client presentations
• Manages/facilitates custom P&T committees for select clients
• Able to analyze & interpret benefit designs
• Clearly communicates analytical and reporting needs to supporting departments
• Identifies opportunities to increase efficiency
• Mentors clinical coordinators, as needed
• Company thought leader
• Functional SME
• Broad business approach
• Resource to senior leadership
• Develops pioneering approaches to emerging industry trends

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:

• Undergraduate degree in applicable area of expertise or equivalent experience
• Hold at least one valid pharmacist license without restrictions
• Must maintain a valid pharmacist license
• Solid clinical and analytic background

Preferred Qualifications:

• Bachelor of Science in Pharmacy or Doctor of Pharmacy degree 
• 3+ years of managed care or PBM experience
• 2+ years of client facing or clinical account management experience

*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 $112,700 - $193,200 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.