Pharmacy Appeals Clinician

MedImpact; United States; Remote; USD 7,187,000 - 13,009,000; Full time

Benefits offered by this job

Medical / Dental / Vision / Wellness

Paid Time Off

Incentive Compensation

401K with Company match

Life and Disability Insurance

Tuition Reimbursement

Employee Referral Bonus

Job summary

MedImpact, a San Diego-based pharmacy benefit manager, seeks an Appeal Clinical Specialist to independently conduct clinical reviews of medical records, apply clinical criteria, and determine benefit coverage for members. The role emphasizes timely, accurate reviews, regulatory compliance, and collaboration with Prior Authorization and Appeals teams to support cost-effective drug therapy.

Candidates must have a PharmD and 3+ years of experience, with deep knowledge of managed care pharmacy and

Qualifications

• PharmD plus 3+ years’ experience or equivalent combination of education and experience, and 1 year of SME in respective areas.
• Current, unrestricted Registered Pharmacist license in good standing in any US state.
• Strong computer skills with Microsoft Office and Microsoft Outlook; familiarity with databases and internet searches.

Responsibilities

• Provide appeal clinical support services to client plans, including clinical review, analysis, recommendation, decision and documentation of appeal requests.
• Review medication request guidelines for clinical appropriateness and operational efficiency; assist in updating guidelines.
• Provide drug information support with literature documentation for prior authorization decisions; prepare meeting materials.
• Coordinate and assist in utilization and compliance reporting for client plans; ensure timely preparation of plan data and presentations.
• Coordinate projects related to appeal program development, implementation and communications.

Skills

Clinical reviews

Regulatory compliance

Decision making

Communication skills

Education

PharmD

Job description

MedImpact, a San Diego-based pharmacy benefit manager, seeks an Appeal Clinical Specialist to independently conduct clinical reviews of medical records, apply clinical criteria, and determine benefit coverage for members. The role emphasizes timely, accurate reviews, regulatory compliance, and collaboration with Prior Authorization and Appeals teams to support cost-effective drug therapy.

Candidates must have a PharmD and 3+ years of experience, with deep knowledge of managed care pharmacy and