Clinical Appeals Review And Compliance Specialist (pharmd) at MedImpact

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.

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.