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

Realistic Job Preview Video Remote in Vermont or Maine 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…