Sr. Network Program Specialist - Telecommute

UHG Schaumburg, IL

About the Job

If you want to achieve more in your mission of health care, you have to be really smart about the business of health care. Challenge yourself, your peers and our industry by shaping what health care looks like and doing your life's best work.(sm)


The Senior Network Program Specialist in the Pharmacy Credentialing Department must act with an extreme sense of urgency to resolve highly sensitive and sometimes escalated provider issues related to pharmacy denials and terminations within OptumRx network. As a Senior Network Program Specialist - we will depend on you to communicate some of our most critical information to the correct individuals regarding appeals and terminations and decisions. You will support teams with reviewing, researching, and understand how the pharmacy review was processed and why it was denial or termination. You will need a high degree of follow through, attention to detail, and proficiency with verbal and written communication.


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


Primary Responsibilities:

  • Analyze / research / understand how the pharmacy review was processed and why it was denial or termination.
  • Obtain relevant records to submit appeals for additional review, as needed
  • Leverage appropriate resources to obtain all information relevant to the appeal
  • Identify and obtain additional information needed to make an appropriate determination
  • Work with applicable internal and external stakeholders to obtain additional information relevant to the pharmacy appeal including internal / external legal counsel
  • Identify and obtain additional information needed to make an appropriate determination
  • Determine whether additional appeal documents are required prior to routing to another department or for internal committee review
  • Document final determination of appeals using appropriate templates, communication processes, etc.
  • Strong understanding of business communication guidelines
  • Communicate appeal information to appellants within the required timeframe
  • Communicate appeal issues / outcomes to all appropriate internal or external stakeholders (e.g., providers, regulatory agencies, plan administrators, etc.)
  • Understand and adhere to applicable federal/state laws and regulations
  • Understand and adhere to applicable documentation handling policies and regulations (e.g., document security, retention)
  • Maintain and enhance existing process documents
  • Identify gaps and inefficiencies in existing policies and procedures and suggest effective and efficient solutions
  • Draft edits and changes as needed and as business evolves and new processes are introduced
  • Adapt departmental plans and priorities to address business and operational challenges
  • Responsible for the timely submission of accurate reporting and deliverables as outlined by the management / project 
  • Assisting in or leading various special projects as directed by Management 
  • Solve moderately complex problems and/or conduct moderately complex analyses
  • Attention to detail and the ability to follow directions and process steps
  • Strong verbal and written communication skills are also required
  • Work with minimal guidance; seek guidance on only the most complex tasks

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:

  • Undergraduate degree
  • 1+ years of experience within the healthcare industry
  • 1+ years of experience working with appeals, grievances and member / pharmacy complaints
  • Strong organizational and interpersonal skills
  • Ability to communicate effectively (clear and concise notes, and written communication)
  • Ability to compose written correspondence free of grammatical errors with complex information that can be easily understood
  • Ability to work independently to prioritize and organize work with minimal guidance
  • Ability to prioritize multiple tasks in an environment of rapid change
  • Intermediate proficiency in MS Office (Outlook, Excel, Access and PowerPoint)
Preferred Qualifications:                                                        
  • National Pharmacy Technician Certification
  • Pharmacy Benefit Management (PBM) knowledge / experience
  • Project management experience
  • 1+ years of customer response / customer service experience
  • 1+ years of experience working in pharmacy environment

Soft Skills:

  • Ability to make fact-based decisions
  • Detail oriented analytic thinker
  • Able to manage assigned work with minimal oversight
  • Ability to work effectively in a changing environment
  • Ability to proactively determine needs and develop steps to accomplish goals
  • Ability to remain focused and productive each day though tasks may be repetitive

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

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


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.   


Job Keywords:  Sr. Network Program Specialist, Telecommute, Remote, Work from Home