Clinical Appeals Review and Compliance Specialist (PharmD)
MedImpact Healthcare Systems, Inc., San Diego, CA, United States
### 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!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:ComposureDecision QualityOrganizational AgilityProblem SolvingCustomer FocusDrive for ResultsPeer RelationsTime ManagementDealing with AmbiguityLearning on the FlyPolitical 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
#J-18808-Ljbffr
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!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:ComposureDecision QualityOrganizational AgilityProblem SolvingCustomer FocusDrive for ResultsPeer RelationsTime ManagementDealing with AmbiguityLearning on the FlyPolitical 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
#J-18808-Ljbffr