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 Experience

CL11 - 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 strong computer skills with Microsoft Office and Microsoft Outlook; good working familiarity with databases and internet searches.

Certificates, Licenses, Registrations

Candidates must possess and maintain a current, unrestricted Registered Pharmacist license in good standing in any state within the United States.

Ability to obtain Kentucky licensure within three (3) months of hire.

Other Skills and Abilities

• Excellent working knowledge of all types of pharmacy services with an emphasis on the managed health care environment.

• Expertise in clinical application of pharmacy practice.

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 work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. 

• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Language Skills

• Ability to write reports, business correspondence and procedure manuals.

• Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. 

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. Ability to maintain clear near visual acuity at approximately 20 inches or less (i.e., “close vision”) to accurately read fine print, view computer screens, and handle small objects. Requires adequate color vision and depth perception to support safety and precision in detail-oriented tasks.

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 a full-time non-exempt position requiring one to be able to work overtime from time to time to get the job done. Therefore, one must have the ability to work nights, weekends or on holidays as required. This may be changed at any time to meet the needs of the business. The typical working hours for this position 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.