The Access & Reimbursement Appeal Supervisor will be responsible for supervision of access and reimbursement specialist and clinical team within the Optum Frontier portfolio. The supervisor will have direct oversight of team members that may work onsite or remotely across the country. Under direct supervision from the Associate Director of Access and Reimbursement, the Supervisor will be responsible for direct oversight of the team of specialists. This specialized team is responsible for the initiation and ongoing follow up of all prior authorization, financial assistance and appeals processes. The team triages prescriptions and medical orders to participating pharmacies and providers once all coverage obstacles have been resolved. This position requires a leader that can accurately provide directions, teach researching techniques, address and communicate medical and prescription insurance coverage requirements as well as a comprehensive knowledge of Medicare, Medicaid and commercial plan structures and standards.This position will provide coaching, mentoring, and support in the development of staff and recognize individual and team success that result in a high-level of team engagement and commitment.
You9ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:- Work directly with leadership on recommended staffing needs using time studies and workforce management tools
- Collaborate with peer leaders across Access & Reimbursement to ensure business needs are addressed, organizational and departmental priorities are aligned, and shared goals are achieved
- Focus on employee development and continuous coaching through monthly touch bases, performance scorecard reviews, and interim and annual performance evaluations
- Manage employee schedules ensuring fair and consistent practices
- Ensure policies and procedures are being followed. Become a subject matter expert on all workflow and policies to inform of work instruction and job aid content needs
- Work directly with training team to ensure all team members are trained to and compliant with policies and procedures and work instructions
- Ensure team members remain compliant with all necessary licensure and continuing education requirements
- Partner with leaders across departments to anticipate and address client needs, ensuring alignment, effective execution, and delivery of exceptional service outcomes. Navigate a highly matrixed organization using strong relationship building skills and clear communication in both verbal and written form
- Drive understanding of systems to partner with leadership on implementation teams to be a subject matter expert in capabilities with understanding to inform on gaps and provide optionality for forward planning of successful implementations
- Monitor performance metrics and hold self and team members accountable to established productivity, quality, and service standards, identifying opportunities for improvement and refinement as needed
- Ensure performance is tracked accurately and reviewed in a timely and consistent manner utilizing established tools and processes to support employee development, accountability, and continuous improvement. Participate and lead monthly meetings
- Provide recommendations to IT partners on system enhancements to better drive performance and quality
- Willingness to jump in and be an operator to ensure patients9 needs are met
- Maintains a working knowledge of program guidelines, FAQ9s, products and therapeutic areas related to assigned programs
- Responsible for reviewing, interpreting and reacting to data provided by clients and customers
- Knowledgeable and proficient in the entire prior authorization and appeals process for prescriptions medications, infusions, medical procedures and devices
- Oversee clinical and operational support activities to ensure consistent execution, quality outcomes, and alignment with established business objectives, workflows, and service standards
- Keeps current with existing treatment trends, treatment standards and updated indications related to assigned programs in order to complete pharmacy PA and Appeal forms and to write letters of medical necessity when applicable
- Monitor performance trends, operational outcomes, and quality measures to identify opportunities for process optimization, continuous improvement, and enhanced patient access
- Knowledgeable and proficient in Medical and pharmacy benefit structure of all major payer types including Medicare, Medicaid, and private commercial
- Knowledgeable and proficient in Claims billing procedures of key payers as defined by plan
- Keeps current with the requirements and eligibility criteria for copay assistance from public, private and non-profit organizations related to assigned programs in order to assist customers with enrolling into third party financial assistance opportunities when applicable
- Coordinates the triage of patient, prescription and/or medical orders to the appropriate partner for fulfillment or administration
- Coordinates with board licensed healthcare professionals including but not limited to nurses, pharmacists, or supervised pharmacy interns for information needed to complete Prior Authorizations, Appeals and third-party financial assistance forms
- Follows up with pharmacy plans, medical plans and third-party financial assistance organizations for general information, status updates and determination details within specified timeframes
- Effectively explains approval or denial details with customers in a manner that is easily understood to fit the needs of the intended audience
- Completes test claims or electronic verification of benefits when applicable
- Maintains company, employee and customer confidentiality as well as compliance with all HIPAA regulations
- Accurately documents all customer communications in an appropriate and professional manner within specified timeframes
- Communicates customer statuses to the appropriate parties at specified intervals or as needed
- Resolves customer issues through basic troubleshooting and escalates potential problems or issues that require management9s attention in a timely manner
- Accurately collect the information required for each program and capture the information in a Customer Relationship Management system (CRM) or database
- Recruit and hire employees to support the organizational structure of site to include onsite employees, telecommute, and remote workforce Supports special projects, strategic initiatives, and other responsibilities as assigned by the Associate Director of Access & Reimbursement in support of business and operational needs
You9ll 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:
- Active, unrestricted, pharmacist license
- 3+ years of hands-on pharmacy prior authorization and appeals experience
- 3+ years of experience performing clinical review and writing clinical criteria
- 2+ years of hands-on Pharmacy Claims Processing, Benefit Verification or Prior Authorization, Appeals processing experience
- 1+ years of experience in a supervisory or lead role
- Specialty Pharmacy experience
- Demonstrated ability to provide quality customer service
- Ability to manage more than one project or task at a time
- Meet deadlines and proactively communicates roadblocks
- Speak, listen, and write in a clear, thorough and timely manner using appropriate and effective communication tools and techniques
- Strive for thoroughness and accuracy when completing tasks
- Ability to work independently
- Solid knowledge of Internet navigation and research
- Willingness to learn and grow in the position
- Participate in continuous quality improvement activities
- Team player and collaborate across functions
- Proven ability to set priorities and manage team to meet key objectives of the business
Preferred Qualifications:- Rare Disease Specialty Pharmacy experience
- Pharmacy Accreditation experience
- Medical Billing/Coding experience
- Experience working in a matrixed environment, call center, operations environment
*All employees working remotely will be required to adhere to UnitedHealth Group9s 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, you9ll 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.
