Clinical Appeals Review and Compliance Specialist (PharmD)

Exemption Status:
United States of America (Exempt)

$108,515 - $152,464 - $196,412

"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 Clinical Appeals Review & Compliance Specialist, directly reports to the Appeal and Grievance Supervisor, Clinical Programs serving as a clinical and operational support resource for the Appeals Clinical Team. This position is responsible for reviewing Appeals for commercial and Part D, rendering determinations based on established clinical guidelines, plan criteria, regulatory requirements, documented procedures, and clinical judgment. The Clinical Appeals Review & Compliance Specialist assist the clinical team with appeal processing questions and issue resolution, tracking assigned work queues, identifying volume fluctuations, and communicating workflow concerns to management for direction. The Clinical Appeals Review & Compliance Specialist works closely with the Appeals and Grievances Supervisor, Clinical Programs and the Management Team to identify and escalate identified issues, and provide feedback regarding process observations encountered during routine case review activities. Responsibilities include, but not limited to, providing clinical training activities as assigned, support implementation of appeal process updates under Management direction, and completing other operational tasks as determined by Supervisor.

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

• Serves as a clinical reviewer and provides subject matter support to the Appeals Clinical team.
• Able to perform independent research of available medical literature, internal and external guidelines, compendium sources of drug information, and plan benefit documents to render appeal determinations. Perform retrospective case review for appropriateness as required by management team.
• Assist Supervisor with PA audit team and other internal teams to investigate and respond to appeal determination questions relevant to commercial and CMS Part D activity.
• Assists the Supervisor with the completion of CMS client audits as needed.
• Assists with issues directly related to clinical appeal processing and review as needed.
• Develops capability to use all MedImpact systems relevant to the appeal clinical review requirements.
• Other duties as assigned including, but not limited to, representing Appeals and Grievance in internal and external meetings related to appeals processing and as approved by management.

Supervisory Responsibilities


No supervisory responsibilities

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

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 Experience

PharmD and 3+ years' experience or equivalent combination of education and experience, and 1 year of SME in respective areas

Computer Skills

To perform this job successfully, an individual should have knowledge of Microsoft Office Suite and a working knowledge of relational databases.

Certificates, Licenses, Registrations

Current, unrestricted license as a Registered Pharmacist in any state of the United States required.

Other Skills and Abilities

• Data analysis and claims research experience preferred.
• Capability to work with complex systems and analyze data for trends.
• Analytical skills with Health Informatics experience preferred.
• Experience in promoting disease management or drug cost management programs preferred.

Reasoning Ability

• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Mathematical Skills

• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.

Language Skills

• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

Competencies To perform the job successfully, an individual should demonstrate the following 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. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).

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). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is an exempt level position requiring the incumbent to work the hours required to fully accomplish job responsibilities and reasonably meet deadlines for work deliverables. The individual must have the flexibility to work beyond traditional hours and be able to work nights, at weekends or on holidays as required. Work hours may be changed from time to time to meet the needs of the business. Typical core business 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.

The Perks:

• 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

To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to

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. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Equal Opportunity Employer, Male/Female/Disabilities/Veterans
OSHA/ADA:

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

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.