Appeals Clinical Specialist

Summary:  The Appeals Clinical Specialist manages accessibility, quality, and cost-effectiveness of drug and medical therapy for members and providers. This position focuses on initiating, supporting, and continuing cost-effective, rational drug, and disease therapy, utilizing distinct but inter-related 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.

Supervisory Responsibilities  

This job has no supervisory responsibilities.

Client Responsibilities

This is primarily an internal client facing position but may require external client communication from time to time. The incumbent is required to have excellent customer service skills and interpersonal communication skills (listening/verbal/written).

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 accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience                                               

Pharmacy degree (Pharm. D.) or equivalent along with 2+ years related experience.

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 

Current, unrestricted Registered Pharmacist license in the State of Kentucky.

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 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:

• Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.
• Cost Consciousness - Works within approved budget; Develops and implements cost saving measures; Contributes to profits and revenue; Conserves organizational resources.
• Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
• Verbal Communication - Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
• Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

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 accommodations 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 occasionally 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 10 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 accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

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 non-exempt position requiring one to be able to work overtime from time to time in order 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 6:00am to 6:00pm PST. The individual must be available to work assigned rotating weekends including on call shifts.

Travel

This position may require occasional travel and attendance at conferences and meetings.