Pharmacist PA/Appeals

About the Role

Optum is a global organization dedicated to improving health outcomes through technology. As a Prior Authorization Pharmacist, you will play a crucial role in the clinical review, decisioning, and communication processes for pharmacy prior authorization and appeals requests. This remote position offers flexibility for residents of Vermont or Maine.

Key Responsibilities

• 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.
• Apply clinical and benefit criteria to support approval, denial, recommendation, or escalation decisions, while clearly documenting 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.
• Demonstrate strong attention to detail when reviewing clinical information, prescription details, diagnosis information, benefit criteria, and supporting documentation.
• 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 requiring 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.
• Promote a culture of safety that is equitable, transparent, and engaging for patients, family caregivers, and the healthcare workforce.
• Enhance workforce safety and well-being.

Work Schedule

• 8-hour shift, Monday - Friday, between 8am - 8pm EST.
• Rotating on-call weekend responsibilities on Saturdays or Sundays.
• Overtime and holidays as required by business needs.

Requirements & Tech Stack

• Intermediate level of proficiency with Microsoft Excel, Word, Outlook, and Teams.
• 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.
• 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.

Qualifications

• Bachelor of Pharmacy or Doctor of Pharmacy degree from an accredited pharmacy program.
• 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.
• Must reside in Maine or Vermont.

Preferred Qualifications

• 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.

Soft Skills

• Strong verbal and written communication skills.
• Strong attention to detail.
• 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.
• Critical thinking, problem-solving, and sound professional judgment.
• Ability to receive feedback, adapt to coaching, adjust performance, and support continuous improvement.