Clinical Appeals Review and Compliance Specialist (PharmD)

About the role

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.