Appeals Clinical Specialist

MedImpact Healthcare Systems, Inc.•San Diego, CA

4d•$52 - $94•Onsite

About The Position

The Appeals Clinical Specialist independently conducts clinical reviews as part of the appeals process. The role evaluates medical records, applies clinical criteria and guidelines, and makes determinations regarding benefit coverage. It ensures appeal reviews are accurate, timely, and compliant with regulatory, accreditation, client, and organizational standards. The position supports the accessibility, quality, and cost-effectiveness of drug and medical therapy for members and providers, and helps maintain rational, cost-effective drug and disease therapy through clinical appeal reviews. The Appeals team oversees the operational and clinical aspects of appeals, including intake, case processing, clinical determinations, notifications, and compliance. This role provides appeal clinical support to client plans and may support medication-request guideline development, drug information research, utilization and compliance reporting, and appeal program projects. It primarily supports internal clients and may periodically interact with external clients. The position is full-time and non-exempt. It is typically scheduled Monday through Friday, 8:00 a.m. to 5:00 p.m., with overtime and availability for nights, weekends, or holidays as business needs require. The role is on-site at the San Diego headquarters or another company location, with remote work possible with management approval based on business requirements. No travel is required, though attendance at local conferences or meetings may be required.

Requirements

PharmD and at least 3 years of experience, or an equivalent combination of education and experience, plus 1 year of subject matter expertise in the respective area.
Current, unrestricted Registered Pharmacist license in good standing in a U.S. state.
Ability to obtain Kentucky licensure within three months of hire.
Strong computer skills with Microsoft Office and Microsoft Outlook, and working familiarity with databases and internet searches.
Excellent working knowledge of pharmacy services, particularly in managed healthcare.
Expertise in the clinical application of pharmacy practice.
Ability to solve practical problems and interpret written, oral, diagrammatic, or schedule-based instructions.
Ability to work with mathematical concepts, including probability, statistical inference, fractions, percentages, ratios, and proportions.
Ability to write reports, business correspondence, and procedure manuals; present information effectively in one-on-one and small-group settings; and read and interpret business, professional, technical, and regulatory materials.
Strong customer service, interpersonal, verbal, written, and active listening skills.
Ability to work overtime and nights, weekends, or holidays as required by business needs.
Ability to perform the stated physical demands, including sitting, standing, walking, using hands, reaching, occasionally lifting or moving up to 25 pounds, and maintaining close vision, color vision, and depth perception.

Responsibilities

Provide appeal clinical support services to client plans, including clinical review, analysis, recommendations, decisions, and documentation of appeal requests in accordance with client contracts, External Review Organization requirements, and appeal delegation agreements.
Review medication-request guidelines for clinical appropriateness and operational efficiency, and assist with revising or creating guidelines as needed.
Provide drug information support and research clinical literature to support prior authorization decisions when indicated.
Assist with Pharmacy and Therapeutics meeting agendas and related materials, including clinical and financial reviews of drugs, drug classes, disease-state therapies, and drug formularies.
Coordinate and assist with utilization and compliance reporting for client plans, including timely preparation and review of plan data and client presentations when required.
Coordinate and assist with projects related to appeal program development, implementation, and internal and external communications.
Provide feedback to the Prior Authorization team and Appeals and Grievances Coordinators on appeal cases referred for clinical review.
Complete appeal reviews accurately and on time in accordance with regulatory, accreditation, organizational, and client performance standards.
Support accessibility, quality, and cost-effectiveness of drug and medical therapy for members and providers.