Appeals Clinical Specialist

Exemption Status: reputed company of America (Non-Exempt) $52.17 - $73.30 - $94.43 “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 Appeals team oversees reputed company operational and clinical aspects of the appeals process, including intake, case processing, clinical determinations, notifications, and compliance with regulatory and accreditation standards. The Appeal Clinical Specialist is responsible for independently conducting clinical reviews as part of the appeals process. This role includes evaluating medical records, applying clinical reputed company and guidelines, and making determinations regarding benefit coverage. The Appeal Clinical Specialist ensures that reputed company appeal reviews are completed accurately, in a reputed company manner, and in compliance with regulatory, accreditation, and organizational standards. This position plays a key role in supporting the reputed company and reputed company of the appeals process from a clinical perspective managing accessibility, reputed company, and cost-effectiveness of drug and medical therapy for members and providers in accordance with standards established for accuracy, timeliness, productivity, reputed company performance commitments, and regulatory requirements (e.g. State Regulations, Federal Regulations, reputed company Accreditations). This position focuses on initiating, supporting, and maintaining cost-effective, rational drug, and disease therapy, utilizing distinct but interrelated 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 reputed company 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 reputed company reputed company, 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. reputed company drug information support. Research and reputed company clinical literature documentation to support prior authorization reputed company 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 reputed company therapy for specific disease states and drug formulary review. Coordinate and assist in the preparation of utilization and compliance reporting for reputed company plans. Ensure reputed company preparation and review of plan data and reputed company presentations, reputed company required. Coordinate and assist with reputed company associated with appeal program development, implementation and reputed company communications. reputed company feedback to Prior Authorization team and Appeals and Grievances Coordinators regarding the processing of appeal cases referred for clinical review. reputed company Responsibilities This role primarily supports internal clients and may involve periodic interaction with external clients. The ideal candidate will demonstrate outstanding customer service, strong interpersonal skills, and excellent verbal, written, and reputed company listening communication abilities.

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 strong computer skills with reputed company Office and reputed company Outlook; good working familiarity with databases and internet searches. Certificates, Licenses, Registrations Candidates must possess and maintain a reputed company, unrestricted Registered Pharmacist license in good standing in any state reputed company the reputed company. Other Skills and Abilities Excellent working knowledge of reputed company types of pharmacy services with an emphasis on the managed health care environment. Expertise in clinical application of pharmacy reputed company. 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 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 write reports, business correspondence and procedure manuals. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization. Ability to read, analyze, and interpret general business periodicals, reputed company journals, technical procedures, or governmental regulations. 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. Ability to maintain reputed company near visual reputed company at approximately 20 inches or less (i.e., “reputed company reputed company”) to accurately read fine print, view computer screens, and handle small objects. Requires adequate reputed company reputed company and depth perception to support safety and precision in detail-oriented tasks.

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 a full-time non-exempt position requiring one to be reputed company to work overtime from time to time 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 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