Appeals Clinical Specialist

Employment Information

Exemption Status: United States of America (Non-Exempt)

Pay Range: $52.17 - $73.30 - $94.43 (actual compensation may vary based on experience, education, qualifications, and other factors)

This position is not eligible for sponsorship.

Job Description

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 independently conducts clinical reviews, evaluates medical records, applies clinical criteria and guidelines, and makes determinations regarding benefit coverage. The Specialist ensures all appeal reviews are completed accurately, timely, and in compliance with regulatory, accreditation, and organizational standards. The role supports the integrity and quality of the appeals process, managing accessibility, quality, and cost‑effectiveness of drug and medical therapy for members and providers.

Essential Duties and Responsibilities

• Provide appeal clinical support services to client plans contracting for appeal clinical services—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; assist in revising and creating new or existing medication request guidelines as indicated.
• Provide drug information support by researching and documenting clinical literature to support prior authorization decisions; prepare Pharmacy and Therapeutics meeting agenda and associated 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.
• 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.

Client Responsibilities

This role primarily supports internal clients and may involve periodic interaction with external clients. The ideal candidate demonstrates outstanding customer service, strong interpersonal skills, and excellent verbal, written, and active listening communication abilities.

Qualifications

Education and Experience

PharmD and 3+ years’ experience or equivalent combination of education and experience, and 1 year of SME in respective areas.

Computer Skills

Strong computer skills with Microsoft Office and Microsoft Outlook; good working familiarity with databases and internet searches.

Certificates, Licenses, Registrations

Maintain a current, unrestricted Registered Pharmacist license in good standing in any U.S. state.

Other Skills and Abilities

• 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.

Reasoning Ability

• 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.

Mathematical Skills

• 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.

Language Skills

• 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.

Competencies

• 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

Physical Demands

The employee regularly sits and talks or hears; also stands, walks, uses hands to fret, handle, or feel and reach with hands and arms. Occasionally lifts or moves up to 25 pounds. Requires clear near visual acuity at approximately 20 inches or less; adequate color vision and depth perception are required.

Work Environment

The work environment is typically moderate in noise level and may involve exposure to moving mechanical parts, high or precarious places, fumes, airborne particles, toxic or caustic chemicals, outdoor weather conditions, and risk of electrical shock or vibration.

Work Location

On-site at the San Diego Headquarters or other company location, or from a remote location with management approval based on business requirements. Must provide adequate support to internal clients and be available for regular interactions and coordination with other employees, colleagues, clients, or vendors.

Working Hours

Full-time non‑exempt position requiring overtime as needed. Typical hours: Monday through Friday from 8:00 am to 5:00 pm. Nights, weekends, or holidays may be required.

Travel

No travel required; attendance may be required at local conferences and meetings.

The Perks

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus

Equal Opportunity Employer

We are an Equal Opportunity Employer: Male/Female/Disabilities/Veterans.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.