Clinical Appeals Strategist

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

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