Clinical Nurse Practitioner or Pharmacist - Prior Authorization or Appeals - Specialty Infusion

The Clinical Pharmacist or Clinical Nurse Practitioner will focus on providing evidence - based and clinical guidance to help implement a next - generation comprehensive specialty solutions which will successfully meet clinical, quality, and financial performance objectives. This solution will help ensure providers deliver high - quality, evidence-based and cost - efficient specialty care for our clients. As such, this newly created role requires an innovative, hands-on, action-oriented clinical expert. The position will serve as a key Specialty medicine expert dedicated to helping ensure high levels of quality, affordability, and member and provider satisfaction.

Working hours: A 40-hour work week, the shift will be determined by the hiring manager upon hire.

• Shift 1: Monday - Friday 8 hour
• Shift 2: Tues - Saturday 8 hour
• Shift 3: Wed - Saturday 10 hour
• Shift 4: Sunday - Thursday 8 hour
• Cannot start earlier than 7am CST
• Weekend Requirement: 1 Saturday per month, 1 Sunday per quarter
• Holiday Requirement: 3 holidays per year

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

Primary Responsibilities

• Support utilization review determinations for specialty medication populations, as well as broader case and disease management programs, to promote optimal clinical outcomes
• Provide clinical expertise in the development, implementation, and continuous improvement of specialty medication utilization management programs
• Serve as a subject matter expert on evidence-based clinical guidelines, ensuring policies, procedures, and decision-making processes reflect current clinical best practices
• Conduct dosage-based clinical reviews to ensure appropriate medication use and adherence to established guidelines
• Perform pre-service reviews for specialty medications to assess medical necessity and appropriateness of care
• Complete documentation audits to ensure compliance with organizational standards and regulatory requirements
• Conduct and support physician-led clinical audits to evaluate quality, consistency, and compliance
• Develop and deliver clinical education and training for internal teams and stakeholders
• Analyze clinical and operational data, including quality metrics, claims data, health records, and utilization trends, to identify opportunities for improving patient outcomes, care delivery, and process efficiency
• Collaborate with cross-functional teams to support quality improvement initiatives and enhance clinical program effectiveness
• Perform additional duties and special projects assigned

Required Qualifications

• High School Diploma/GED
• Licensed Nurse Practitioner OR Pharm D (License must be in state of residence, current and unrestricted)
• 3+ years of clinical experience
• 3+ years of experience working with evidence-based medicine related to specialty medications
• 2+ years of experience administering and/or advising on specialty medication treatment plans (utilizing/reviewing medical case notes, medication list, lab results)
• 2+ years of hospital experience
• 1 + years of experience handling sensitive issues with members and providers in a confidential manner
• Access to a designated quiet workspace in your home (separated from non-workspace areas) with the ability to secure Protected Health Information (PHI)
• Live in a location where there is a UnitedHealth Group approved high-speed internet connection to leverage existing high-speed internet

Preferred Qualifications

• Experience in utilization management
• Additional Licensure in NM, MN, AZ
• Experience working in managed care, medical care delivery systems, utilization management, case management, disease management, quality management, product development and/or peer review
• Demonstrated ability to work cross-functionally to gain credibility, influence and partner with other clinical and non-clinical professionals

Soft Skills

• Ability to work independently