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Job description
Realistic Job Preview Video
Remote in Vermont or Maine
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.
The essential functions of a Senior Pharmacy PA/Appeals Technician include supporting the prior authorization and appeals process by providing accurate, timely, and professional service to members, providers, pharmacists, and internal business partners. This role is responsible for receiving, researching, documenting, and processing prior authorization requests for formulary and non-formulary medications through multiple intake channels, including phone, fax, and electronic systems. The technician reviews request information against established criteria, verifies required member, provider, medication, diagnosis, benefit, and plan details, identifies missing information, and routes clinical questions or judgment-based decisions to the appropriate pharmacist or clinician. The position requires strong attention to detail, compliance with regulatory and contractual requirements, adherence to turnaround times (TATs) and service level agreements (SLAs), and clear documentation of all interactions and case actions.
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 within the states of Vermont or Maine, you will enjoy the flexibility to telecommute as you take on some tough challenges.
Primary Responsibilities: Manage a high volume of inbound and outbound calls, averaging 50+ daily, while maintaining professionalism, accuracy, and customer service expectations
Respond to prior authorization inquiries and requests from providers, pharmacies, members, and internal partners using approved scripts, reference materials, job aids, policies, and procedures
Review and process prior authorization requests through multiple computer systems, ensuring required information is complete, accurate, and documented in accordance with compliance, regulatory, client, and business requirements
Research formulary, benefit, medication, eligibility, and plan-specific information to help resolve prior authorization questions, benefit issues, and case-processing barriers
Gather and verify member, provider, prescriber, pharmacy, medication, diagnosis, and clinical support information needed for pharmacist consultation or clinical review
Identify missing or incomplete information and take appropriate follow-up action, including outbound calls or routing to the appropriate team, pharmacist, or clinician when needed
Prioritize work to support required turnaround times for standard, expedited, urgent, and client-specific prior authorization requests
Maintain productivity, quality, schedule adherence, attendance, and documentation standards in a fast-paced, metric-driven environment
Resolve issues and complaints in a timely, professional manner and escalate concerns when additional support, clinical review, or leadership guidance is required
Additional Qualifications/Responsibilities: Apply sharp attention to detail when reviewing prior authorization requests, using established criteria and guidelines to support accurate and compliant case processing
Accurately document call details, case actions, approvals, denials, transfers, escalations, 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 recognize when a request requires pharmacist review, clinical clarification, additional documentation, or escalation to leadership
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: Support patient safety and quality by completing work accurately, documenting thoroughly, and following approved criteria, policies, procedures, and regulatory requirements
Identify and escalate potential patient safety, medication, benefit, system, privacy, or quality concerns in a timely manner
Maintain a safe and secure workspace and promptly notify leadership if equipment, system access, information security, or workspace conditions may affect safe and compliant work
Participate in quality improvement efforts by applying feedback, correcting errors, and consistently following updated job aids, workflows, and standard operating procedures
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 a Health Saving account
Dental, Vision, Life& AD&D Insurance along with 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.)
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications: Active and unrestricted Pharmacy Technician licensure, registration, or certification as required by the state of residence and business needs. Candidates must meet and maintain all applicable state, certification, and company requirements throughout employment Pharmacy Technician Certification Board (PTCB)
State Board of Pharmacy licensure or registration in state of residence, if required
ExCPT - Pharmacy Technician Certification through the National Healthcareer Association (NHA)
Other approved prior authorization or pharmacy technician certification, as accepted by the business
6+ months of experience in customer service, customer relations, healthcare, pharmacy, call center, or direct interaction with healthcare professionals
Basic level of proficiency with Microsoft Excel, Word, Outlook, and Teams, including the ability to create, edit, save, send, and manage basic documents, spreadsheets, emails, and communications
Basic level of ability to navigate multiple systems, screens, job aids, knowledge articles, and electronic workflows while maintaining accuracy during calls and case processing
Ability to work 8-hour shift Monday - Friday between 8am - 8pm EST with rotating on-call weekend responsibilities on Saturdays or Sundays, overtime, evenings, & holidays (work schedule will vary based on business needs)
Currently located in the state of Maine or Vermont
Preferred Qualifications: Experience with prior authorization, appeals, pharmacy benefit management, prescription drug benefits, formulary review, pharmacy claims, or healthcare coverage processes
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
Experience working in a high-volume, production-based, quality-monitored, or compliance-driven environment
Familiarity with pharmacy terminology, medication names, brand and generic drug names, SIG codes, benefit terminology, and healthcare documentation standards
Soft Skills: Strong verbal and written communication skills with the ability to explain information clearly, professionally, and accurately to providers, members, pharmacists, and internal partners
Strong attention to detail and ability to apply established criteria, workflows, and documentation standards consistently
Ability to manage competing priorities, follow through on assigned tasks, and meet deadlines in a fast-paced, metric-driven environment
Critical thinking, problem-solving, and sound judgment to identify incomplete information, workflow barriers, compliance concerns, or situations requiring escalation
Ability to accept feedback, adjust performance, and support continuous improvement in quality, productivity, service, and compliance outcomes
Physical Requirements and Work Environment: . click apply for full job details
Worksite address
gorham, ME, 04038, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.