Appeals Clinical Specialist

Job Overview

Exemption Status: United States of America (Non‑Exempt). Salary range: $52.17 – $73.30 – $94.43. Pay scale information is not necessarily reflective of actual compensation. This position is not eligible for sponsorship.

Responsibilities

• Oversee all operational and clinical aspects of the appeals process, including intake, case processing, clinical determinations, notifications, and compliance with regulatory and accreditation standards.
• Conduct independent clinical reviews as part of the appeals process; evaluate medical records, apply clinical criteria and guidelines, and make determinations regarding benefit coverage.
• Ensure all appeal reviews are completed accurately, in a timely manner, and in compliance with regulatory, accreditation, and organizational standards.
• 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.
• Review medication request guidelines for clinical appropriateness and operational efficiency; assist in revision and creation of new or existing medication request guidelines.
• Provide drug information support; research and provide clinical literature documentation to support prior authorization decisions.
• Prepare 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.
• 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.

Qualifications

• Education: PharmD and 3+ years’ experience or equivalent combination of education and experience, and 1 year of subject‑matter expertise in respective areas.
• License: Current, unrestricted Registered Pharmacist license in good standing in any U.S. state.
• Computer skills: Strong proficiency with Microsoft Office and Outlook; familiarity with databases and internet searches.
• Technical skills: Excellent working knowledge of all types of pharmacy services with emphasis on the managed health care environment; expertise in clinical application of pharmacy practice.
• Reasoning and problem‑solving: Ability to interpret a variety of instructions, solve practical problems and apply mathematical concepts.
• Communication: Ability to write reports, business correspondence and procedure manuals; effectively present information in one‑on‑one and small group situations.
• 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.

Benefits

• 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

Work Environment

Typical business office with computers and printers; moderate noise level. Employees may be exposed to moving mechanical parts, fumes, airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration.

Physical Demands

Regularly required to sit, talk or hear, stand, walk, use hands and arms; occasionally lift or move up to 25 pounds; maintain near visual acuity 20 inches.

Working Hours

Full‑time non‑exempt position requiring ability to work overtime from time to time, including nights, weekends or holidays. Typical hours Monday through Friday 8:00am to 5:00pm.

Travel

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

Equal Opportunity Employer

MedImpact Healthcare Systems, Inc. is an equal opportunity employer. We comply with OSHA/ADA and make reasonable accommodations for qualified individuals with disabilities.