Supervisor. Appeal Clinical Programs

The Supervisor, Appeal Clinical Programs manages accessibility, quality, and cost-effectiveness of drug and medical therapy for members and providers. This position focuses on supporting the education and training needed by the appeal clinical specialists, which will support cost-effective, rational drug, and disease therapy, utilizing distinct but inter-related management and cross-departmental functions.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Works with Appeals and Grievances (A&G) Manager to oversee the compliance, timeliness, and effectiveness of delivering high quality outcomes for the Appeal Clinical programs at MedImpact. Assist with the development and administration policies, business processes and quality standards. In conjunction with the A&G Manager, appeal processing ensures that appeal decisions are on time and meet the quality levels expected by MedImpact's internal and external customers.  Serves as backup  for department Manager.

• Assists team members in process improvement including design of workflow processes and implementation of technology to support these processes; Helps to support workflow by assisting the team with strategic workflow management, scheduling, and adjusting the workflow in the event of a staffing challenge.

• Provides oversight and expertise to the Appeal Clinical Review team with the assistance of the Lead Appeal Pharmacist.

• Monitors and provides feedback to improve quality of services provided by Appeals operations group including design, oversight, and review of quality and productivity reports; Helps to conduct the Inter- Rater Reliability Reporting and conveying areas for improvement to clinical staff; Assists audit team in investigations of appeals, in conveying audit feedback to both PA and Appeal clinical team and developing Appeal process enhancements.

• Participates in the design and implementation of appeal and other required programs for new and existing clients, including design and development of standard and customized processes. Helps to maintain on-going client interaction for key clients regarding appeal program assessment and improvement.

• Partners with A&G Manager and internal teams to develop policies and procedures to document and maintain compliance with NCQA standards and state and federal legislation and regulations as applicable.  Assists with administration of the Utilization Management Oversight (UMOC).

• Assists with regularly scheduled individual and departmental meetings that will cover training and operational issues for the Appeal Clinical Reviews and Quality Improvement. Oversees the continuing development of clinical staff and recommend appropriate training modules. Works to operationalize the distance-learning program and the scheduling and monitoring of new appeal clinical specialist onboarding.

• Collaborates with Prior Authorization’s teams, Customer Service, Benefits and Pharmacy Network operational management staff as well Clinical Consultative Services (CPM Team) and Drug Information/P&T support staff regarding application of Appeals program performance standards. Participates in cross-functional meetings as necessary.

• Participates in quarterly MedImpact P&T Committee meetings as requested by the A&G Manager or  the Medical Director.

• Provides 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 and Utilization Management delegation agreements.

• Provides drug information support. Researches and provides clinical literature documentation to support appeal decisions as indicated. Prepares associated meeting materials including clinical and/or financial analysis including, but not limited to drug classes, appeals overturned, and External Review Organization (ERO) determinations.

• Provides feedback to A&G Supervisor (operations) and Lead Coordinator regarding the processing of appeal cases referred for clinical review. Provides in-service education to Appeal Clinical Specialist, A&G Coordinates and as requested by the A&G manager or Medical Director

• The Supervisor, Appeal Clinical Programs is a hands-on role, consisting of approximately 80% supervisory activities and 20% appeal clinical specialist administration tasks. This breakdown will fluctuate in accordance with business need, as some days will require more supervision and others will require for appeal administration.

Supervisory Responsibilities

Assists with the supervision of the Lead Appeal Pharmacist and appeal clinical pharmacists and supervises others in the Appeal review process in the Appeal and Grievance department. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities for training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

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; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients; Assist with difficult or emotional client situations.

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

Doctor of Pharmacy (or equivalent combination of education and experience) along with at least 4 years related experience. At least 2 years of leadership experience required.

Computer Skills

To perform this job successfully, an individual should have knowledge of Microsoft Office, Outlook and use of relational databases.

Certificates, Licenses, Registrations

Current, unrestricted Registered Pharmacist license in the State of California or a state of the United States.

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.
• 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.
• 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.
• 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.