Clinical Appeals Pharmacy Leader

Summary of Job

Review appeals for clinical appropriateness and makes clinical decisions on approvals. Partner with G&A team to review pharmacy appeals, pharmacy benefit appeals, and related medical appeals, including process refinement, with responsibility for Level 1 and Level 2 appeals. Review and report analysis of appeals determination trends and quality measures with pharmacy benefits management (PBM) vendor and company-wide quality and compliance teams. Responsible for Independent Review Entity (IRE) responses in partnership with PBM and G&A team. Responsible for managing performance of staff and activities related to Pharmacy quality and compliance including monitoring and trending of key performance indicators (KPIs) and compliance reports for reporting and regulatory submissions. Provide active oversight and ongoing direction for the Pharmacist Appeals team and quality assurance process including case review, review with staff and monthly scoring. Direct reporting on productivity, clinical quality, compliance with state and federal pharmacy requirements, and appeals volume by line of business. Lead, develop and enforce standards of quality, quality assurance, and monitoring for the Pharmacist Appeals team and utilization oversight.

Responsibilities:

• Responsible for clinical decision making on pharmacy appeals related to medical necessity and clinical policy interpretation and application.
• Oversee the Pharmacist Appeals team.
• Manage the day-to-day functions of the Clinical Pharmacy quality assurance process.
• Direct and ensure workforce modeling and score card development.
• Lead the development of training and analytical materials for Stars, NCQA.
• Collaborate with health plan market leads on Plan-sponsored initiatives designed to assist and empower members in closing gaps.
• Drive and manage an effective corrective action and preventive action (CAPA) process including the tracking, trend analysis, root cause analysis, and implementation of process improvement measures.
• Analyze audit and inspection findings and suggest remediation as well as maintain overview of CAPA responses and resulting measures.
• Determine objectives and approaches to strategy for cost containment and clinical enhancements.
• Develop, implement, and present pharmacy-related UM reporting, including UM dashboard, practitioner scorecard, timeliness, denial language, and federal/state regulatory compliance.
• Responsible for developing and overseeing training to ensure awareness of and compliance with organizational objectives and applicable laws and regulatory requirements.
• Design, review, and use plan tools, reports and system results to conduct weekly, monthly, and quarterly case and appeals reviews with department staff. Maintain staff-specific scorecards to be shared monthly.
• Responsible for development and maintenance of Utilization Management Trees to improve efficiency of the staff.
• Participate in the monthly G&A Committee to include Step-Protocol Review, Non-Formulary Review, Subcommittee Management (meetings/minutes), High Cost Therapies, and updates.
• Design and develop Appeals policies, procedures, and operating guidelines.
• Other duties/projects as assigned.