Appeals Clinical Specialist

MedImpact Healthcare Systems, Inc.•San Diego, CA

2d•$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, ensuring reviews are accurate, timely, and compliant with regulatory, accreditation, and organizational standards. It supports the accessibility, quality, and cost-effectiveness of drug and medical therapy for members and providers, consistent with accuracy, timeliness, productivity, client commitments, and regulatory requirements. The Appeals team oversees operational and clinical elements of the appeals process, including intake, case processing, clinical determinations, notifications, and compliance. This position provides clinical support for appeal reviews and helps initiate, support, and maintain cost-effective, rational drug and disease therapy through related management and cross-departmental functions. The position primarily supports internal clients and may periodically interact with external clients. It is based on-site at the San Diego Headquarters or another company location, or remotely with management approval based on business requirements. The typical schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. The role is full-time and non-exempt, may require overtime, and requires the ability to work nights, weekends, or holidays when needed. No travel is required, although attendance may be required at local conferences and meetings.

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 areas.
Current, unrestricted Registered Pharmacist license in good standing in any U.S. state; candidates must maintain the license.
Strong computer skills, including Microsoft Office and Microsoft Outlook, and working familiarity with databases and internet searches.
Excellent working knowledge of pharmacy services, particularly in the managed health care environment.
Expertise in the clinical application of pharmacy practice.
Ability to solve practical problems and interpret instructions in written, oral, diagram, or schedule form.
Ability to work with probability, statistical inference, geometry, trigonometry, fractions, percentages, ratios, and proportions.
Ability to write reports, business correspondence, and procedure manuals; present information effectively to customers, clients, and employees; and read and interpret business, professional, technical, and regulatory materials.
Strong customer service, interpersonal, verbal, written, and active listening skills.
Ability to sit, stand, walk, talk or hear, use hands to handle objects, and reach with hands and arms; occasionally lift or move up to 25 pounds; and maintain close vision, adequate color vision, and depth perception.
Ability to work overtime and nights, weekends, or holidays as required.

Responsibilities

Provide appeal clinical support services to client plans, including clinical review, analysis, recommendation, decision, and documentation of appeal requests as required by 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 document and support prior authorization decisions as indicated.
Prepare Pharmacy and Therapeutics meeting agendas and related materials when needed, 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 regarding appeal cases referred for clinical review.