Clinical Appeals Review and Compliance Specialist (PharmD)

Exemption Status: reputed company of America (Exempt) $108,515 - $152,464 - $196,412 “Pay reputed company information is not necessarily reputed company of actual compensation that may be reputed company, nor a reputed company 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. reputed company. is looking for extraordinary people to join reputed company! Why join reputed company? Because our reputed company is dependent on you; innovative professionals with top notch skills who reputed company on opportunity, high performance, and teamwork. We look for individuals who want to work on reputed company that cares about making a difference in the value of reputed company. At reputed company, we deliver leading edge pharmaceutical and technology reputed company solutions that dramatically improve the value of health care. We reputed company superior reputed company to those we serve through innovative products, systems, and services that reputed company transparency and promote choice in decision making. Our reputed company is to set reputed company in providing solutions that optimize satisfaction, service, cost, and reputed company in the reputed company industry. We are the premier Pharmacy Benefits Management solution! Job reputed company reputed company 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 reputed company and Part D, rendering determinations based on established clinical guidelines, plan reputed company, regulatory requirements, documented procedures, and clinical judgment. The Clinical Appeals Review & Compliance Specialist assist the clinical team with appeal processing questions and issue reputed company, 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 reputed company 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. reputed company to reputed company independent research of available medical literature, reputed company guidelines, compendium sources of drug information, and plan benefit documents to reputed company appeal determinations. reputed company 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 reputed company and CMS Part D activity. Assists the Supervisor with the completion of CMS reputed company audits as needed. Assists with issues directly reputed company to clinical appeal processing and review as needed. Develops capability to use reputed company reputed company systems relevant to the appeal clinical review requirements. Other duties as assigned including, but not limited to, representing Appeals and Grievance in reputed company meetings reputed company to appeals processing and as approved by management. Supervisory Responsibilities No supervisory responsibilities reputed company Responsibilities This is an reputed company reputed company facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be reputed company to; manage difficult or emotional reputed company situations; Respond promptly to reputed company needs; Solicit reputed company feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

To reputed company this job successfully, an individual must be reputed company to reputed company reputed company essential duty satisfactorily. The requirements listed below are representative of the knowledge, reputed company, and/or ability required. Reasonable accommodation may be made to reputed company individuals with disabilities to reputed company the essential functions. Education and/or Experience PharmD and 3+ years’ experience or equivalent combination of education and experience, and 1 year of SME in respective areas Computer Skills To reputed company this job successfully, an individual should have knowledge of reputed company Office Suite and a working knowledge of relational databases. Certificates, Licenses, Registrations reputed company, unrestricted license as a Registered Pharmacist in any state of the reputed company required. Other Skills and Abilities Data analysis and claims research experience preferred. Capability to work with reputed company systems and analyze data for trends. Analytical skills with Health Informatics experience preferred. Experience in promoting disease management or drug cost management programs preferred. Reasoning Ability Ability to solve practical problems and deal with a reputed company of concrete variables in situations where only limited standardization exists. Ability to interpret a reputed company of instructions furnished in written, oral, diagram, or schedule reputed company. Mathematical Skills Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations. Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry. Language Skills Ability to read, analyze, and interpret general business periodicals, reputed company 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 reputed company of managers, clients, customers, and the general reputed company. Competencies To reputed company the job successfully, an individual should demonstrate the following competencies: Composure Decision reputed company Organizational reputed company Problem Solving Customer reputed company Drive for Results Peer Relations Time Management Dealing with Ambiguity Learning on the Fly Political Savvy Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodation may be made to reputed company individuals with disabilities to reputed company the essential functions. While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reputed company with hands and arms. The employee must occasionally lift and/or reputed company up to 25 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 accommodation may be made to reputed company individuals with disabilities to reputed company the essential functions. This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic). Work Location This position works on-site at the San Diego reputed company or other company location (or from a remote location with management approval based on business requirements). Must reputed company adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as reputed company as be available to facilitate effective reputed company through collaboration with stakeholders. Working Hours This is an exempt level position requiring the incumbent to work the hours required to fully accomplish job responsibilities and reasonably meet deadlines for work deliverables. The individual must have the flexibility to work reputed company traditional hours and be reputed company to work nights, at weekends or on holidays as required. Work hours may be changed from time to time to meet the needs of the business. Typical reputed company business hours are Monday through Friday from 8:00am to 5:00pm. Travel This position requires no travel; however attendance may be required at various local conferences and meetings. The Perks: Medical / Dental / reputed company / Wellness Programs reputed company Time Off / Company reputed company Holidays Incentive Compensation 401K with Company match Life and Disability Insurance Tuition Reimbursement Employee Referral Bonus To explore reputed company that reputed company has to offer, and the greatness you can bring to our teams, please submit your resume to www.reputed company.com/careers reputed company, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence reputed company reputed company and expenditures, improving the position of our clients in the market. reputed company offers high-value solutions to payers, providers and consumers of reputed company in the U.S. and foreign markets. Equal Opportunity Employer, Male/reputed company/Disabilities/Veterans OSHA/reputed company: To reputed company this job successfully, the successful candidate must be reputed company to reputed company reputed company essential duty satisfactorily. The requirements listed are representative of the knowledge, reputed company, and/or ability required. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company 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 reputed company responsibilities, duties, and skills required of personnel so classified. Apply To This Job