Appeals Clinical Specialist

MedImpact•San Diego, CA

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 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 appeal clinical reviews. The position provides appeal clinical support to client plans, including clinical review, analysis, recommendations, decisions, and documentation as required by client contracts, External Review Organization requirements, and appeal delegation agreements. It also supports medication request guideline review and development, drug information, clinical literature research, utilization and compliance reporting, and appeal program projects. The role primarily supports internal clients and may periodically interact with external clients. This is a full-time, non-exempt position. The typical schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m.; overtime may be required, and the employee must be able to work nights, weekends, or holidays as needed. The position is based onsite at the San Diego headquarters or another company location, though remote work may be approved by management based on business requirements. No travel is required, although 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 as a subject-matter expert 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, including Microsoft Office and Microsoft Outlook, and working familiarity with databases and internet searches.
Excellent working knowledge of pharmacy services, especially in a 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 mathematical concepts and apply fractions, percentages, ratios, and proportions to practical situations.
Ability to write reports, business correspondence, and procedure manuals; present information effectively in individual and small-group settings; and read and interpret business, professional, technical, and governmental materials.
Outstanding customer service, interpersonal, verbal, written, and active-listening skills.
Ability to work overtime and nights, weekends, or holidays as required.
Ability to meet the physical demands of the role, including sitting, talking or hearing, standing, walking, handling and reaching, occasionally lifting or moving up to 25 pounds, and close visual work.

Responsibilities

Provide appeal clinical support services to client plans, including clinical review, analysis, recommendations, decisions, and documentation in accordance with client contracts, External Review Organization requirements, and appeal delegation agreements.
Review medication request guidelines for clinical appropriateness and operational efficiency.
Assist with revising and creating medication request guidelines.
Provide drug information support.
Research and provide clinical literature documentation to support prior authorization decisions.
As needed, prepare Pharmacy and Therapeutics meeting agendas and materials, including clinical and financial reviews of drugs, drug classes, disease-state therapies, and drug formulary reviews.
Coordinate and assist with utilization and compliance reporting for client plans.
Ensure 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.