Pharmacy Team Lead - Drug Medical Billing - National Remote

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

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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

The Pharmacy Team Lead in Optum Frontier Therapies will be on the team of an exciting new business serving patients with rare diseases, pharma manufacturers, and providers by dispensing and servicing therapies at the frontier of healthcare. As a new Optum business, we are building on our strengths but also challenging the status quo. We are creating a business that is designed to specifically serve the unique needs of rare disease patient populations and support the emerging therapies, which require enhanced services and new capabilities over traditional specialty pharmacies. Our mission, ‘supporting people with compassion while creating access to therapies at the frontier of health care,’ and vision, ‘that all people, no matter how unique, can access a better tomorrow’ are what drive and motivate us, as part of the larger UnitedHealth Group mission ‘to make the health system work better for everyone.’

The Pharmacy Team Lead will be responsible for supporting the supervision of access and reimbursement specialist team within the Optum Frontier portfolio. The lead will help with oversight of team members that may work onsite or remotely across the country. Under direct supervision from the Access & Reimbursement Specialist Supervisor, the Lead will be responsible for executing the vison and plan provided by the Access & Reimbursement Supervisor and indirect oversight of the team of specialists. This specialized team is responsible for the initiation and ongoing follow up of all Benefit verification/initiation, 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 take and provide directions, teach researching techniques, and best practices, and 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 support the Supervisor in regards provide training, coaching, mentoring, and support in the development of staff and recognize individual and team success tha t result in a high-level of team engagement and commitment.

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

• Identify trends in billing and follow-up, be able to identify ways in which we can expedite resolution of insurance accounts and identify delays in processing.
• Receive escalations and inquiries from patients and providers, investigate root cause and supply potential resolution as well as keep track of and monitor.
• Knowledgeable and proficient in the entire prior authorization and appeals process for prescriptions medications, infusions, medical procedures, and devices.
• Keeps current with existing treatment trends, treatment standards and updated indications related to assigned programs in order to complete PA and Appeal forms and to write letters of medical necessity when applicable.
• Work directly with Supervisor daily to assist on discussing and planning staffing needs and department goals using time studies and workforce management tools
• Keeps current with existing treatment trends, treatment standards and updated indications related to assigned programs in order to complete medical billing claims
• Ensure department designated SOP’s, process updates and changes, and procedures are being followed by the team.
• Knowledgeable and proficient in Claims billing procedures of key payers as defined by plan
• Knowledgeable and proficient in Medical and pharmacy benefit structure of all major payer types including Medicare, Medicaid, and private commercial
• Other functions and duties, including those of varied scopes, assigned by leadership across all of Optum Frontier Therapies as needed to support the success of our business
• As subject matter expert you will partner with Supervisor on implementations to inform on gaps and provide optionality for forward planning of successful implementations
• Readiness to jump in and be an operator to ensure patients’ needs are met
• Assist in employee development and coaching by pulling, developing, and providing weekly quality reviews, call quality and metrics
• Responsible for reviewing & reconciling items monthly including follow up on any claims or billing resolution.
• Work with the Supervisor to ensure all team members are trained to policies and procedures and work instructions. Drive understanding of systems amongst team.
• Become a subject matter expert on all workflow and policies to assist on work instruction and job aid content needs.
• Support the development of the team culture. As the Lead Access and Reimbursement Specialist you will play an important role maintaining the morale and spirit of motivation within the department, including the degree of cooperation, communication, and coordination between employees
• Maintains a working knowledge of program guidelines, FAQ’s, products, and therapeutic areas related to assigned programs.
• Oversee the benefit investigation of medical coverage specific to drug coverage, the medical billing of drugs, and the follow-up/collections for government and special term payers.
• Research and retrieve missing EOBs and payments to post them promptly.
• Resolves customer issues through troubleshooting and escalates potential problems or issues that require management’s attention in a timely manner.
• Knowledgeable and proficient in Coding principles, including CPT and HCPCS
• Responsible for accurate and thorough action, follow up, and documentation of information in accordance with procedures.
• Knowledgeable and proficient in Claims billing procedures of key payers as defined by plan
• Track and monitor processed claims, review, and follow to ensure payment, and rebill corrections as needed
• Managing Government payer follow up and working with Finance for account reconciliations
• Support department metrics to ensure the overall objective for the business is met
• Complete a benefits investigation to verify ability to bill the patients’ medical coverage, obtain what the drug coverage is a patient under their plan, what the stipulations to billing the drug is, what plan specific criteria’s must be followed to successfully receive reimbursement for the post service claim billed
• Recognizes and encourages both business and the department’s strategy and goals, conveys updates or changes needed to be successful and drive results.

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:

• Ability to work during our normal business hours of 10:00am – 6:30pm EST. It may be necessary, given the business need, to work occasional overtime.
• 2+ years of hands-on Medical Claims Processing or Medical Billing/Coding experience with a hospital, medical or health service provider, PBM or payor
• 2+ years of leadership experience, including training, and supporting team members
• High School Diploma / GED (or higher)
• Advanced knowledge of medical coding and billing systems and regulatory requirements

Preferred Qualifications:

• Certified through AAPC or AHIMA
• Specialty Pharmacy experience
• Certificate (CPB or Dual Certified [CPB & CPC])
• Current coding certifications with proof of certification with valid certification identification number

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy

S oft Skills:

• Ability to use independent judgment and to manage and impart confidential information
• Be a team player and collaborate across functions
• Strong knowledge of Internet navigation and research
• Good knowledge of auditing concepts and principles
• Demonstrated ability to provide quality customer service
• Speak, listen, and write in a clear, thorough, and timely manner using appropriate and effective communication tools and techniques Willingness to learn and grow in the position
• Ability to manage more than one project or task at a time
• Meet deadlines and proactively communicate roadblocks
• Has been in a startup environment or have been part of building out processes and guidelines
• Strong oral and written communication skills
• Strive for thoroughness and accuracy when completing tasks
• Excellent organization and problem-solving skills
• Participate in continuous quality improvement activities
• Ability to work independently

Careers with Optum . Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

California, Colorado, Connecticut, Nevada, Washington or New York, Rhode Island Residents Only: The salary range for California / Colorado / Connecticut / Nevada / Washington / New York / Rhode Island residents is $22.45 - $43.89.Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives

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.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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