Appeals Clinical Specialist

About the role

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.

Responsibilities

• Provide 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.
• Aid 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.
• 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.
• Cookordination and assistance 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.

Qualifications

• PharmD and 3+ years’ experience or equivalent combination of education and experience, and 1 year of SME in respective areas.
• Strong computer skills with Microsoft Office and Microsoft Outlook; good working familiarity with databases and internet searches.
• Candidates must possess and maintain a current, unrestricted Registered Pharmacist license in good standing in any state within the United States.

Benefits

A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.