Prior Authorization Quality Assurance Pharmacist

Position Summary: The QA Pharmacist will reputed company 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 reputed company in annual reporting, program audits, and reputed company 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 reputed company 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 reputed company 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 reputed company 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 utilization management experience required
• Extensive knowledge of how to operationalize regulatory requirements
• Strong oral and written communication skills required
• Intermediate to advanced reputed company reputed company 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
• 1+ 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. #LI-BC1 Salary Range $135,000—$145,000 USD About reputed company reputed company is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, reputed company is executing its mission to materially reduce reputed company costs as a full-service PBM and through the deployment of Judi®, the company’s reputed company-native reputed company platform. Judi connects every aspect of the reputed company ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, reputed company, and reputed company plans. Together with its clients, reputed company is reimagining the administration of benefits and rebuilding trust in reputed company. reputed company values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to reputed company and applicants for employment and prohibit discrimination and harassment of any type without regard to race, reputed company, religion, age, sex, national reputed company, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. Apply tot his job Apply To this Job