Position Summary:

The QA Pharmacist will use their state regulatory knowledge to perform routine auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of coverage requests and appeals. The QA Pharmacist will utilize a strong comprehension of regulatory requirements to ensure success in annual reporting, program audits, and ad hoc audits.

Position Responsibilities:

• Complete monthly utilization management and appeals performance and process audits in alignment with applicable regulations, accreditation standards, and best practices.
• Create and maintain progress reports and audit results in accordance with regulatory/accreditation requirements and internal processes.
• Present audit results to leadership in a timely manner to address issues and ensure adherence to departmental procedures and regulatory/accreditation requirements (CMS, URAC, NCQA).
• Continuously review and remain informed of all regulatory/accreditation requirements and updates impacting the coverage request and appeals processes.
• Respond to inquiries from internal and external stakeholders regarding quality assurance processes, audit results, and compliance policies and procedures.
• Work independently and with team members as warranted by audit assignment.
• Assist in designing and implementing audit tools and programs, creating QA scorecards and guides in collaboration with all department stakeholders.
• Provide ongoing performance feedback, to team leads to ensure consistent performance.
• Assist management in identifying, evaluating, and mitigating operational, and compliance risks.
• Work in collaboration with operational leaders to identify training opportunities and recommend improvements to Work Instructions, Job Aids, and Policy and Procedures to improve performance.

Minimum Qualifications:

• Active, unrestricted, pharmacist license required
• 2+ years of state regulatory and audit utilization management experience at a PBM or health plan required
• Extensive knowledge of how to operationalize regulatory requirements
• Strong oral and written communication skills required
• Intermediate to advanced Microsoft Excel skills required
• Possess strong analytical skills, attention to detail, quantitative, and problem-solving abilities
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven work environment
• Ability to multi-task and collaborate in a team with shifting priorities

Preferred Qualifications:

• Familiarity/experience with URAC and NCQA accreditation requirements
• Utilization management and/or appeals audit experience
• 3+ years of compliance or regulatory experience at a PBM or health plan

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

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