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, organizational, and client requirements, while supporting the accessibility, quality, and cost-effectiveness of drug and medical therapy for members and providers. The position provides clinical appeal support to client plans, including review, analysis, recommendations, decisions, and documentation. It may also contribute to medication request guidelines, drug information and literature research, Pharmacy and Therapeutics meeting materials, utilization and compliance reporting, and appeal program projects. The role primarily supports internal clients, with periodic interaction with external clients. This is a full-time, non-exempt position. It is typically worked Monday through Friday, 8:00 a.m. to 5:00 p.m., with overtime and the ability to work nights, weekends, or holidays as required. The position is based on-site at the San Diego headquarters or another company location, or remotely with management approval based on business requirements. No travel is required, though attendance at local conferences and 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 areas.
Current, unrestricted Registered Pharmacist license in good standing in a U.S. state; the license must be maintained.
Strong computer skills, including Microsoft Office and Microsoft Outlook, and working familiarity with databases and internet searches.
Excellent working knowledge of pharmacy services, with an emphasis on managed health care.
Expertise in the clinical application of pharmacy practice.
Ability to solve practical problems and interpret instructions in varied formats and situations with limited standardization.
Ability to apply mathematical concepts, including fractions, percentages, ratios, and proportions, to practical situations.
Ability to write reports, business correspondence, and procedure manuals; present information effectively; and read and interpret professional, technical, business, and regulatory materials.
Outstanding customer service, interpersonal, verbal, written, and active listening skills.
Ability to work overtime and nights, weekends, or holidays when required.
Ability to meet the position's physical demands, including sitting, standing, walking, handling objects, reaching, occasionally lifting or moving up to 25 pounds, and maintaining close vision, color vision, and depth perception.

Responsibilities

Provide clinical appeal 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 existing medication request guidelines and creating new guidelines as indicated.
Provide drug information support and research clinical literature to document and support prior authorization decisions as indicated.
Prepare Pharmacy and Therapeutics meeting agendas and materials, which may include clinical and financial reviews of drugs, drug classes, disease-state therapies, and 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 about appeal cases referred for clinical review.
Complete appeal reviews accurately and in a timely manner while complying with regulatory, accreditation, organizational, and client standards.