Description

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together

The Clinical Pharmacist provides comprehensive oversight of prior authorization (PA) processes and serves as a clinical subject matter expert for PA and Appeals teams. This role drives modernization and automation initiatives, ensures regulatory compliance, and leads annual readiness activities, including Medicare Part D Continuation of Care (COCA). The ideal candidate combines clinical expertise with operational acumen, leveraging data-driven insights to enhance utilization management and member experience.

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

Primary Responsibilities:

• Clinical Oversight and Support
  • Ensure accurate and compliant prior authorization decisions through interpretation of clinical criteria and quality audits
  • Act as the primary clinical escalation point for PA and Appeals teams, promoting consistency in adjudication and documentation
  • Maintain evidence-based PA criteria and decision-support tools aligned with CMS guidance, plan benefits, and industry standards
  • Collaborate and engage on authorization effectuation processes (e.g., GPI-level determinations)
• PA Modernization and Automation
  • Identify and prioritize automation opportunities that minimize unnecessary prior authorization requests and streamline clinical workflows
  • Analyze PA trends and root causes to design solutions that reduce administrative burden while maintaining compliance and clinical integrity
  • Develop intelligent automation strategies that integrate predictive analytics and machine-readable logic to proactively approve low-risk requests
  • Collaborate with cross-functional teams to implement user-friendly tools and portals that enhance operational efficiency and member experience
• Utilization Management
  • Collaborate on UM build initiatives and participate in monthly prior authorization performance reviews
  • Support continuous improvement efforts to enhance utilization management outcomes
• Regulatory Readiness and Audits
  • Coordinate and validate annual readiness activities related to prior authorization changes
  • Provide audit support for PDE reviews, ad hoc assessments, and program-level audits
• Medicare Continuation of Care (COCA)
  • Lead COCA implementation, including drug identification in partnership with formulary and strategy teams
  • Ensure COCA processes meet CMS standards and timelines; partner with PBM for operational execution
• Quality, Analytics and Performance
  • Develop and manage clinical quality programs (e.g., inter-rater reliability, decision accuracy, appeals overturn rates)
  • Use data analytics to identify root causes, prioritize improvements, and measure impact
• Collaboration and Stakeholder Engagement
  • Partner with Medical Directors, Compliance, Legal, Product, PBM, UM Operations, Formulary, and Strategy teams for all government programs lines of business including Medicaid and DSNP to ensure alignment, share best practices, and strengthen cross-functional collaboration
  • Communicate complex clinical, operational, and regulatory topics clearly and effectively to diverse audiences, ensuring consistent understanding across internal teams, providers, and stakeholders

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:

• Doctor of Pharmacy (PharmD) with an active, unrestricted pharmacist license
• 5+ years of experience in managed care pharmacy, PBM, health plan, or UM operations with direct PA expertise
• 5+ years of in-depth knowledge of Medicare Part D and CMS guidance, including coverage determinations and redeterminations
• 5+ years of proven experience leading clinical oversight of PA/Appeals teams
• 5+ years of strong analytical skills with proficiency in Excel and/or BI tools (e.g., Power BI, Tableau)
• 5+ years of experience in pharmacy adjudication systems

*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 $110,200 to $188,800 annually based on full-time employment. We comply with all minimum wage laws as applicable.

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.

Requisition #: 2326850

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Requirements