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Quality Assurance (QA) Pharmacist

1 day, 20 hours ago
United States
Full-time
Junior
Manual QA Tester
Quality Assurance and Testing
Apply Now
Capital Rx

Capital Rx

Capital Rx provides comprehensive health benefit management and transparent pharmacy benefit management solutions, integrating various healthcare services to support millions of plan members across diverse sectors.

Health Care Providers & Services
251-1K
Founded 2017
View All Jobs 42

Description

  • Complete monthly utilization management and appeals audits in alignment with regulations, accreditation standards, and best practices.
  • Create and maintain progress reports and audit results in accordance with regulatory, accreditation, and internal requirements.
  • Present audit findings to leadership in a timely manner and address issues affecting compliance and departmental procedures.
  • Monitor regulatory and accreditation updates that impact coverage request and appeals processes.
  • Respond to inquiries from internal and external stakeholders about quality assurance processes, audit results, and compliance policies.
  • Work independently or with team members depending on the audit assignment.
  • Design and implement audit tools, programs, QA scorecards, and guides with department stakeholders.
  • Provide ongoing performance feedback to team leads to support consistent performance.
  • Identify, evaluate, and help mitigate operational and compliance risks.
  • Collaborate with operational leaders to identify training opportunities and recommend improvements to work instructions, job aids, policies, and procedures.

Requirements

  • Active, unrestricted pharmacist license is required.
  • 2+ years of state regulatory and audit utilization management experience at a PBM or health plan is required.
  • Extensive knowledge of how to operationalize regulatory requirements.
  • Strong oral and written communication skills are required.
  • Intermediate to advanced Microsoft Excel skills are required.
  • Strong analytical skills, attention to detail, quantitative ability, and problem-solving skills.
  • Ability to work independently with minimal supervision in a remote, high-volume, metric-driven environment.
  • Ability to multitask and collaborate in a team with shifting priorities.
  • Familiarity with URAC and NCQA accreditation requirements is preferred.
  • Utilization management and/or appeals audit experience is preferred.
  • 3+ years of compliance or regulatory experience at a PBM or health plan is preferred.

Benefits

  • Salary range of $135,000 to $145,000 USD.
  • Remote work in a high-volume, metric-driven environment.

Interested in this position?

Apply directly on the company website

Apply Now

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