Role 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 is responsible for independently conducting clinical reviews as part of the appeals process. This role includes: - Evaluating medical records - Applying clinical criteria and guidelines - Making determinations regarding benefit coverage - Ensuring all appeal reviews are completed accurately and in a timely manner - Supporting the integrity and quality of the appeals process This position focuses on initiating, supporting, and maintaining cost-effective, rational drug, and disease therapy. Essential Duties and Responsibilities - Provide appeal clinical support services to client plan(s) contracting for appeal clinical services, including clinical review, analysis, recommendation, decision, and documentation of appeal requests. - Review medication request guidelines for clinical appropriateness and operational efficiency. - Provide drug information support and research clinical literature documentation to support prior authorization decisions. - Coordinate and assist in the preparation of utilization and compliance reporting for client plans. - 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 - 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. - 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. Requirements - Ability to solve practical problems and deal with a variety of concrete variables. - 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. - Ability to write reports, business correspondence, and procedure manuals. - Ability to effectively present information in one-on-one and small group situations. - 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 physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job: - Regularly required to sit, talk, or hear. - Regularly required to stand, walk, use hands to finger, handle, or feel and reach with hands and arms. - Must occasionally lift and/or move up to 25 pounds. - Ability to maintain clear near visual acuity to accurately read fine print and view computer screens. Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job: - Regularly exposed to moving mechanical parts, high precarious places, fumes, or airborne particles. - Noise level in the work environment is usually moderate. Work Location This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Working Hours This is a full-time non-exempt position requiring the ability to work overtime from time to time. The typical working hours are Monday through Friday from 8:00am to 5:00pm. Travel This position requires no travel; however, attendance may be required at various local conferences and meetings. 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 Company Description MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market.