Appeals Clinical Specialist

MedImpact Healthcare Systems, Inc.•San Diego, CA

4d•$52 - $94•Onsite

About The Position

The Appeals team oversees all operational and clinical aspects of the appeals process, including intake, case processing, clinical determinations, notifications, and compliance with regulatory and accreditation standards. The Appeal Clinical Specialist is responsible for independently conducting clinical reviews as part of the appeals process. This role includes evaluating medical records, applying clinical criteria and guidelines, and making determinations regarding benefit coverage. The Appeal Clinical Specialist ensures that all appeal reviews are completed accurately, in a timely manner, and in compliance with regulatory, accreditation, and organizational standards. This position plays a key role in supporting the integrity and quality of the appeals process from a clinical perspective managing accessibility, quality, and cost-effectiveness of drug and medical therapy for members and providers in accordance with standards established for accuracy, timeliness, productivity, client performance commitments, and regulatory requirements (e.g. State Regulations, Federal Regulations, Professional Accreditations). This position focuses on initiating, supporting, and maintaining cost-effective, rational drug, and disease therapy, utilizing distinct but interrelated management and cross-departmental functions for appeal clinical reviews.

Requirements

PharmD and 3+ years’ experience or equivalent combination of education and experience, and 1 year of SME in respective areas
Strong computer skills with Microsoft Office and Microsoft Outlook; good working familiarity with databases and internet searches.
Candidates must possess and maintain a current, unrestricted Registered Pharmacist license in good standing in any state within the United States.
Excellent working knowledge of all types of pharmacy services with an emphasis on the managed health care environment.
Expertise in clinical application of pharmacy practice.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry.
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to write reports, business correspondence and procedure manuals.
Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Composure
Decision Quality
Organizational Agility
Problem Solving
Customer Focus
Drive for Results
Peer Relations
Time Management
Dealing with Ambiguity
Learning on the Fly
Political Savvy

Nice To Haves

Outstanding customer service, strong interpersonal skills, and excellent verbal, written, and active listening communication abilities.

Responsibilities

Responsible for providing appeal clinical support services to client plan(s) contracting for appeal clinical services.
Support services will include, but not limited to, 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.
Assist in the revision and creation of new or existing medication request guidelines as indicated.
Provide drug information support.
Research and provide clinical literature documentation to support prior authorization decisions as indicated.
May include preparation of Pharmacy and Therapeutics meeting agenda and associated meeting materials including clinical and financial reviews of individual drugs, drug classes, and current therapy for specific disease states and drug formulary review.
Coordinate and assist in the preparation of 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 associated with appeal program development, implementation and internal and external communications.
Provide feedback to Prior Authorization team and Appeals and Grievances Coordinators regarding the processing of appeal cases referred for clinical review.