Pharmacy Utilization RN - CA 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.

Unique opportunity for a UM Nurse to improve patient care and outcomes through completion of utilization management functions for value-based patients in the Optum West region (CA). This is a full-time position with variable hours between 7:00 am to 7:00 pm PST, Monday – Friday (Five 8-hour days).  Rotating weekend coverage. 100% telecommuter position. Under general supervision of the Pharmacy Manager, the RN is responsible for utilization review and the coordination of members Medicare Part B, Commercial, Medicaid medication through UM Pharmacy staff, Medical Directors and various other departments. This position will perform reviews of specialty drugs appropriateness as applicable to Medicare Part B, Commercial, Medicaid benefit. You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Provide summary clinical and ancillary information to Pharmacist, Medical Director for review and decision making for targeted Medicare Part B, Commercial, Medicaid medications Discuss patient care specifics with peers or providers involved in overall patient care and benefits Advocate to pharmacists and others for appropriate decisions (e.g., patient level of care changes) regarding patient health and welfare (e.g., care and service coverage, safety) Research and identify information needed to perform assessment, respond to questions, or make recommendations (e.g., navigate knowledge Library resources, and websites and databases such as MicroMedex and National Comprehensive Cancer Network) Answer members and providers questions regarding care (e.g., medication, treatment) and benefits Apply knowledge of pharmacological and clinical treatment protocol to determine appropriateness of care and treatment requested Demonstrate understanding necessary to assess, review and apply criteria policy (e.g., Milliman guidelines, CMS criteria, medical policy, plan specific criteria) Demonstrate knowledge of process flow of UM including prior authorization, concurrent authorization and/or clinical appeal and grievance reviews Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives. Utilizes independent judgment in problem-solving by developing or adjusting processes and composing procedures Performs all other related duties as assigned