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Capital Rx · 5 months ago

Prior Authorization Quality Assurance Pharmacist

United States

Full-time

Remote

Entry, Mid Level

$135K/yr - $145K/yr

2+ years exp

Capital Rx is a health technology company providing claim administration and technology solutions in the healthcare sector. The QA Pharmacist will perform auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of coverage requests and appeals, while also presenting audit results and assisting in the development of audit tools and programs.

Hospital & Health Care

H1B Sponsor Likely

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

Qualification

Utilization management experienceRegulatory compliance knowledgeAnalytical skillsMicrosoft Excel skillsCommunication skillsMulti-taskingURACNCQAProblem-solving abilitiesAttention to detailTeam collaboration

Required

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 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

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

Company

Capital Rx

Capital Rx is now Judi Health! Navigate to our new page here: https://www.linkedin.com/company/judi-health

Founded in 2017

New York, NY, US

501-1000 employees

https://www.judi.health/about/careers

H1B Sponsorship

Capital Rx has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (3)

2024 (2)

2023 (1)

2022 (1)

2021 (5)