Appeals & Grievances Implementation Specialist

Job Title : Appeals & Grievances Implementation Specialist

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top-notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

The Appeals & Grievances Implementation Specialist reports to the Appeals & Grievances Manager adhering to operational guidance at the direction of the Appeals & Grievances Supervisor and in collaboration with the Prior Authorization Implementation team. This position is responsible for : 1) Implementation of new Appeals and Grievances clients; 2) Maintenance of Business for process application updates as they relate to timers and notifications 3) Vendor Oversight monitoring; 4) Performance Guarantee tracking and oversight. This position is responsible for application configuration and testing of each client's Appeal and / or Grievance program, interfacing with clients for requirements gathering, coordinating the implementation of Appeals & Grievances processes per regulatory requirements, and managing the creation and maintenance of all associated notifications. Must be able to work in teams and manage a project to meet deliverables of the project according to established timelines.

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

• Coordinates client implementations and system conversions by working closely with IT services as well as with the Compliance department, Implementation department, Prior Authorization department, Accreditation team, legal team, client team, and others as may be required.
• Attends various MedImpact implementation meetings such as Implementation status meeting, individual client operations meetings, Implementation Questionnaire (IQ) review, compliance and regulatory meetings, and PA Implementation meetings as required to gather business requirements and share information on client delegation, MedImpact's PA and Formulary program offerings.
• Serves as subject matter expert on implementation activities and processes related to the MedImpact's Appeals and Grievances products and services. Additionally serves as a Medical Affairs resource for related questions and / or inquiries from both internal and external customers.
• Serves as the principal or supporting liaison between MedImpact Medical Affairs, Appeals and Grievances, and the client team during the implementation or conversion process.
• Conducts internal processing platform configuration tasks for implementation and maintenance of business of Appeal and Grievance clients. This includes but is not limited to : client specific timers, letters, reason codes, HiTrust audits, and granting system access.
• Demonstrates system tools to internal and external groups when necessary.
• Responsible for monitoring and tracking vendor activities including productivity, quality, and reporting.
• Maintains confidentiality of all member, provider, client and proprietary information.
• Maintain, monitor, and report all information and data related to Performance Guarantees.
• Maintains and exercises competency to perform transactions in relevant MedImpact systems.
• Remains knowledgeable regarding company policies and procedures and current developments within operational departments.

Supervisory Responsibilities : No supervisory responsibilities.

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 manage difficult or emotional client situations; respond promptly to client needs; solicit client feedback to improve service; respond to requests for service and assistance from clients; and meet commitments to clients.

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 : BS / BA and 3+ years' experience or equivalent combination of education and experience.

Computer Skills : Advanced knowledge of MS Office / Word, Excel, PowerPoint, Visio, and Outlook. Experience as a user of multiple business software applications. Advanced working knowledge of key business applications such as MedOptimize, MedAccess, and others as applicable to the role preferred but not required.

Certificates, Licenses, Registrations : Current and unrestricted State Pharmacy Technician License required and / or National Pharmacy Technician certification preferred.

Other Skills and Abilities : Strong interpersonal skills with the ability to establish and maintain effective business relationships with clients, all levels of employees, and in multiple departments.

Reasoning Ability : Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.

Mathematical Skills : Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Language Skills : Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.

Competencies To perform the job successfully, an individual should demonstrate the following competencies :

Physical Demands : The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform 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 reach with hands and arms. The employee must occasionally lift and / or move 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 accommodations may be made to enable individuals with disabilities to perform 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 Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours : This is a full-time non-exempt position requiring one to be able to work overtime from time to time in order 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 :

MedImpact, is a privately-held pharmacy benefit manager (