This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description HealthPartners is hiring a Clinical Review Pharmacist. Service excellence is to be centered on patient care and patient relationships and is the responsibility of all employees. Teamwork is the norm and all employees will be held accountable to work as effective team members. The role involves: - Reviewing, approving, and denying prior authorization requests in compliance with pharmacy policies, procedures, and standards. - Providing support to physicians and pharmacy staff regarding prior authorization questions. - Reviewing prior authorization requests for medical policy drugs and pharmacy benefit drugs; making coverage determinations for drug products according to member benefits and coverage criteria. - Contributing to the development, maintenance, and communication of utilization management and exception criteria. - Providing clinical guidance and support to the Pharmacy Customer Service Assistants and other Pharmacy staff when requested. - Conducting research and analysis of coverage determinations and appeals on an ad hoc basis. - Providing support and follow-up for escalated clinical issues. - Researching drug information to maintain drug knowledge and disease state understanding for application to drug coverage reviews. - Applying drug knowledge and evidence from literature to specific case situations, discussions with Medical Directors, and other peer review groups. - Providing effective drug information and consultation to professional staff, providers, patients, and members. - Ensuring strict adherence to the requirements of CMS, DHS, MDH, and other regulatory agencies. - Supporting and cooperating with other departments’ operation initiatives. - Maintaining a professional image. - Adhering to the established Group Health, Inc., patient-service standards. - Performing other duties as assigned. Qualifications - Must be a graduate from an accredited college of pharmacy and licensed as a pharmacist in the state of Minnesota. - Must maintain this license in good standing as required by Minnesota law. - Must meet one of the following: - Pharm.D. - One year of recent experience in a managed care pharmacy setting. - One year of recent clinical pharmacy experience that includes prior authorization experience. - Demonstrated knowledge of pharmacodynamics, pharmacokinetics, pathophysiology, and therapeutic disease states commonly found in ambulatory patients. - Demonstrated competency in all professional aspects of pharmacy. - Strong leadership and organizational skills; maturity and dependability are essential. - Ability to organize and function under stress with many interruptions. - Ability to establish and maintain effective, friendly, and courteous working relationships with coworkers, physicians, and patients. - Strong communication/listening skills and good telephone etiquette. - Ability to accept and implement change. - Ability to tactfully resolve complaints. Requirements - Experience working with pharmacy technicians (preferred). - Experience working with Microsoft suite of products (preferred). - Knowledgeable in CMS and DHS regulations as well as other compliance-related rules and entities (preferred). Benefits - Comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. - Commitment to nurturing diverse talents and valuing dedication. - Support for work-life balance. - Goal to help you thrive physically, mentally, emotionally, and financially. Company Description At HealthPartners, we believe in the power of good – good deeds and good people working together. We’re a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improves lives around the world. At HealthPartners, everyone is welcome, included, and valued. We’re working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change.

Join Us in this Amazing Opportunity The Team You’ll Join We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a Behavioral Health Utilization Management Medical Case Manager and help shape the future of healthcare where you’ll be an integral part of our BHI - BH Utilization Management team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework. - If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. The Medical Case Manager (BHI Utilization Management) will be responsible for reviewing and processing requests for authorization and notification of behavioral health services from health professionals, clinical facilities and ancillary providers. You will be responsible for prior authorizations, concurrent review and related processes. You will utilize CalOptima Health’s medical criteria, policies and procedures to authorize referral requests from behavioral health professionals, clinical facilities and ancillary providers. You will directly interact with providers and facilities and serve as a resource for their needs. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: - 85% - Utilization Management Services - Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. - Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. - Reviews requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request. - Responsible for mailing rendered decision notifications to the provider and member, as applicable. - Screens inpatient and outpatient requests for the Medical Director’s review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director’s decision and documents follow-up in the utilization management system. - Completes the required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates. - Contacts the health networks and/or CalOptima Health Customer Service regarding health network enrollments. - Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or through verbal communication if the issue is of an urgent nature. - Refers cases of possible over/under utilization to the Medical Director for proper reporting. - Completes care coordination activities as related to Transition Care Management (TCM) activities. - Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and the existence of coverage specific to the line of business. - 10% - Administrative Support - Assists manager with identifying areas of staff training needs and maintains current data resources. - Complies with data tracking protocols. - 5% - Other - Completes other projects and duties as assigned. Do You Have What the Role Requires? - Current California unrestricted license such as LCSW, LPCC, LMFT or RN and related required education PLUS 3 years of clinical experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. You’ll Stand Out More If You Possess the Following: - Utilization management reviewer experience. - Managed care experience. - Behavioral health clinical experience. What the Regulatory Agencies Need You to Possess? - Current California unrestricted license such as LCSW, LPCC, LMFT or RN. Your Knowledge & Abilities to Bring to this Role: - Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds. - Work independently and exercise sound judgment. - Communicate clearly and concisely, both orally and in writing. - Work a flexible schedule; available to participate in evening and weekend events. - Organize, be analytical, problem-solve and possess project management skills. - Work in a fast-paced environment and in an efficient manner. - Manage multiple projects and identify opportunities for internal and external collaboration. - Motivate and lead multi-program teams and external committees/coalitions. - Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Your Physical Requirements (With or Without Accommodations): - Ability to visually read information from computer screens, forms and other printed materials and information. - Ability to speak (enunciate) clearly in conversation and general communication. - Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions. - Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting. - Lifting and moving objects, patients and/or equipment 10 to 25 pounds Ways We Are Here For You - You’ll enjoy competitive compensation for this role. - Our current hiring range is: Pay Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615). - The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors. - This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**) - A comprehensive benefits package - CalPERS pension program and additional retirement packages. - Additional benefits and perks including: - A generous PTO program - A quality work life balance - Various wellness programs - Tuition Reimbursement - Professional development opportunities - Career development opportunities - Flexible scheduling - And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families. Our Work Environment: If located at the 500, 505 Building or a remote work location: - Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. - There are no harmful environmental conditions present for this job. - The noise level in this work environment is usually moderate. If located at PACE: - Work is typically indoors in a clinical setting serving the frail and elderly. - There may be harmful or hazardous environmental conditions present for this job. - The noise level in this work environment is usually moderate to loud. If located in the Community: - Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. - Employee will occasionally work outdoors in varied temperatures. - There may be harmful or hazardous environmental conditions present for this job. - The noise level in this work environment is usually moderate to loud. Why Join Us? We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare. What's Your Next Step? All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is March 10, 2026 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. Our Commitment to You Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet. We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

ABOUT ACCOMPLISH Accomplish Health is a rapidly-growing, venture-backed leader providing telemedicine obesity care. We are redefining remote medical weight management and medical bariatrics through evidence-based stigma-free care, managed by obesity specialized clinicians and dietitians. Our mission is to provide people living with obesity with access to the high-quality evidence-based treatment they deserve. Our comprehensive clinical model leverages pharmacotherapy (prescription drugs), nutrition therapy, health coaching, and connected devices (i.e. scales, blood pressure cuffs), which has generated best-in-class clinical outcomes for our patients (12-month Weight Loss of 22% vs. industry norm of 5-16%) and in turn extraordinarily high patient satisfaction (NPS of ~90, Satisfaction Levels of >95%). By providing care in a completely virtual environment, we can provide enhanced access for patients in even the most remote locations, while providing clinical opportunities to medical professionals across the country. We partner with health systems and bariatric practices across the US, to provide our obesity care services to their patients in need, either through direct referral partnerships or joint ventures, with strong traction to date. Key Responsibilities: - Deliver prompt and insightful triage (via phone or messaging) to aid patients in making informed healthcare decisions, applying critical thinking and clinical assessment skills alongside established protocols to ensure accurate patient care. - Communicate proactively with providers and care team members to ensure seamless coordination and timely resolution of patient needs. - Consistently provide confidential, high-quality, stigma-free, person-centered care and a superior patient experience. - Record complete, timely, and legible medical documentation, ensuring appropriate encounter-related billing services. - Utilize and support a detailed, software-enabled clinical model that leverages pharmacotherapy, nutrition therapy, health coaching, and remote physiological monitoring to help patients with obesity and other metabolic conditions achieve their weight loss and wellness goals. Qualifications: - BSN plus a minimum of 3 years of recent related experience as a Registered Nurse. Experience in obesity medicine and/or bariatrics a plus. - Either an active license in a compact state OR an active unrestricted eNLC. - Strong communication, clinical assessment, and computer skills required. - Demonstrated excellent written/verbal communication skills. - Competency in the genetic, biological, environmental, social, and behavioral factors that contribute to obesity and a thorough understanding of the treatment of obesity. - Candidates should have strong computer skills and excellent phone skills to work with providers, patients, and administrators What We Offer: - A competitive salary commensurate with your experience - Excellent benefits including healthcare, dental and vision - Participation in the Employee Stock Option Plan - Flexible PTO - Opportunities for professional development and advancement. - A collaborative and supportive work environment. More about Accomplish Health: - We are a remote-first progressive and technology focused workplace. - We are a mission-driven organization made up of veteran entrepreneurs and healthcare professionals passionate about treating obesity and other metabolic conditions. - We are a data-centric, objective focused, collaborative, and iterative culture where feedback and open communication are encouraged. - Our investors are top venture capitalists and entrepreneurs who have backed or founded unicorns like Zocdoc, Grove, Ginkgo Bioworks, Sweetgreen, Udemy, Clover Health, ASAPP and Moat. - We care about the well being and growth of our patients, employees, and communities. Accomplish Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary: The Prior Authorization Clinician is responsible for reviewing all proposed hospitalization, home care, and inpatient/outpatient services for medical necessity and efficiency to ensure members receive the appropriate and timely care to support members in achieving optimal health outcomes. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Functions/Responsibilities: · Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines applying evidenced-based InterQual® criteria, Medical Policy and benefit determination. · Performs utilization review activities, including pre-certification, concurrent and retrospective reviews according to guidelines. · Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria · Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. · Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication. · Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available. · Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT). · Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures. · Sends appropriate system-generated letters to provider and member · Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses · Follows all departmental policies and workflows in end-to-end management of cases. · Participates in team meetings, education, discussions, and related activities · Maintains compliance with Federal, State and accreditation organizations. · Identifies opportunities for improved communication or processes · May participate in audit activities and meetings · Documents rate negotiation accurately for proper claims adjudication · Identify and refer potential cases to Care Management · Performs all other related duties as assigned Qualifications: Education: · Nursing degree or diploma required Preferred/Desirable: · Bachelor’s degree · Medicare and Medicaid knowledge Experience: · 2+ years prior authorization experience and evidence-based guidelines (InterQual Guidelines) · Managed care experience · All employees working remotely will be required to adhere to WellSense’s Telecommuter Policy Licensure, Certification or Conditions of Employment: · Active RN License in the state of NH, or a compact eligible state that includes NH · Pre-employment background check · Ability to take after hours call, including evening/nights/weekends Competencies, Skills, and Attributes: · Strong oral and written communication skills. · Strong clinical judgement and critical thinking skills to assess complex cases and determine appropriate levels of care. · Excellent communication and interpersonal skills to engage effectively with internal and external stakeholders · Ability to work independently in a remote environment while maintaining adherence to timeliness and regulatory requirements. · Proficiency in Microsoft Office applications and data management systems. · Demonstrated organizational and time management skills · Strong analytical and clinical problem-solving abilities with focus on quality improvement initiatives Working Conditions and Physical Effort: · Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions. · Fast paced and dynamic work environment requiring adaptability and focus. · Minimal physical effort required; primarily desk-based tasks such as documentation and virtual meetings. · Regular and reliable attendance is essential. Compensation Range $35.58 - $51.44 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing. Note: This range is based on Boston-area data, and is subject to modification based on geographic location. About WellSense WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees