Senior Pharm PA/Appeals Technician - Remote in Maine or Vermont

Senior Pharmacy PA/Appeals Technician

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

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
• 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:

• Frequent speaking and listening using a headset; sitting for extended periods; use of hands and fingers across a keyboard and mouse; and extended periods working at a computer
• 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 telecommuters, 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

*All employees