Remote Pharmacist w/ OptumRx – Job Opportunity – Insight Global Health

The Pharmacist, Prior Authorization (PA) & Appeals, is responsible for reviewing and evaluating prior authorization and appeals requests to determine coverage based on clinical guidelines, pharmacy policies, and health plan benefits. In this fast-paced, high-volume environment, the pharmacist works closely with physicians, healthcare providers, pharmacy technicians, and internal teams to gather and assess clinical information, make evidence-based coverage determinations, recommend formulary-compliant and cost-effective treatment alternatives, and ensure compliance with federal and state regulations. The role requires strong clinical judgment, attention to detail, effective communication skills, and the ability to manage competing priorities while meeting productivity and quality standards. Additionally, the pharmacist supports quality assurance initiatives, resolves provider and pharmacy inquiries, participates in process improvement efforts, and contributes to a collaborative, customer-focused team environment. Maintain full compliance with state and federal pharmacy laws, Medicare Part D, Medicaid, and commercial benefit regulations. Accurately document case decisions in accordance with internal protocols, auditing standards, and confidentiality policies. Effectively manage case volume by organizing workload, setting daily priorities, and meeting productivity and quality benchmarks. Adapt to fluctuating demands while maintaining accuracy and professionalism under pressure.

• Review and evaluate prior authorization and appeal requests for pharmacy coverage determinations
• Assess clinical information and apply pharmacy policies, clinical guidelines, and health plan benefits
• Collaborate with physicians, healthcare providers, pharmacy technicians, and internal teams
• Recommend formulary-compliant and cost-effective treatment alternatives
• Ensure compliance with state and federal pharmacy regulations, Medicare Part D, Medicaid, and commercial benefit requirements
• Manage a high-volume caseload while maintaining quality and productivity standards
• Document case decisions and assist with quality assurance and process improvement initiatives