Clinical Appeals Review And Compliance Specialist (pharmd)

VERDEGARD ADMINISTRATORS LLC

San Diego, California, United States
Base: $108,515 - $152,464 - $196,412; bonus/equity...
Fully remote
Review commercial and part d appeal determinations
Apply clinical guidelines and plan criteria
Conduct retrospective case reviews
The Clinical Appeals Review & Compliance Specialist is responsible for reviewing appeals for commercial and Part D plans to render determinations based on clinical guidelines and regulatory requirements

Job Summary

  • The Clinical Appeals Review & Compliance Specialist is responsible for reviewing appeals for commercial and Part D plans to render determinations based on clinical guidelines and regulatory requirements.
  • MedImpact offers a comprehensive benefits package including medical, dental, vision, wellness programs, paid time off, and a 401K with company match.
  • This role requires the ability to perform independent research of medical literature and internal guidelines to support the Appeals Clinical Team.

Matching Summary

The Clinical Appeals Review & Compliance Specialist is responsible for reviewing appeals for commercial and Part D plans to render determinations based on clinical guidelines and regulatory requirements.

Salary

Base: $108,515 - $152,464 - $196,412; Bonus/Equity: Not specified; Benefits: Medical/Dental/Vision/Wellness, PTO, 401K match, Tuition Reimbursement

Skills & Requirements

Must-have

  • Review commercial and Part D appeal determinations
  • Apply clinical guidelines and plan criteria
  • Conduct retrospective case reviews
  • Research medical literature and compendium sources
  • Manage complex client situations

Nice-to-have

  • Data analysis and claims research experience
  • Health informatics analytical skills
  • Experience in disease management programs
  • Drug cost management program experience
  • Ability to work with complex systems

Key Requirements

  • PharmD degree required
  • 3+ years of relevant experience
  • Current unrestricted pharmacist license in any US state
  • Knowledge of Microsoft Office Suite and relational databases
  • No sponsorship available

Work Rights

Not specified

Tailored Resume

Cover Letter