Appeals Clinical Specialist

medimpact; San Diego (CA); On-site; USD 72,000 - 130,000; Full time

Job summary

MedImpact Healthcare Systems, Inc. is seeking an Appeal Clinical Specialist to oversee the clinical review of appeals and ensure compliance with regulatory and accreditation standards.

You will evaluate medical records, apply guidelines, and determine benefit coverage for members and providers. The role focuses on initiating, supporting, and maintaining cost-effective drug and disease therapy reviews, with collaboration across departments to meet client performance commitments and quality

Qualifications

• Clinical review of medical records and documentation.
• Understanding of regulatory and accreditation standards.

Responsibilities

• Provide appeal clinical support services including review, analysis, recommendation, decision and documentation of appeal requests.
• Review medication request guidelines for clinical appropriateness and operational efficiency.
• Provide drug information support and literature documentation for prior authorization decisions.
• Coordinate utilization and compliance reporting for client plans.
• Assist with project work for appeal program development and internal/external communications.
• Provide feedback to related teams regarding processing of appeal cases.

Skills

Clinical review

Medical records

Regulatory compliance

Job description

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

$52.17 - $73.30 - $94.43

"Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate."

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact?

Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

Summary

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.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• 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.

Client Responsibilities

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

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experi