Capital Rx · 3 hours ago

Quality Assurance (QA) Pharmacist - Commercial

United States

Full-time

Remote

Entry, Mid Level

$125K/yr - $135K/yr

2+ years exp

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Responsibilities

Act as a subject matter expert for Commercial Non-ERISA Fully Insured, Self-Funded, and Exchange Plans governed by state regulations.

Complete monthly initial prior authorization and appeals performance and process audits in alignment with best practices and any applicable ERISA and state regulations.

Create and maintain progress reports and audit results in accordance with regulatory requirements and internal processes.

Present audit results to leadership in a timely manner to address issues and ensure adherence to departmental procedures and regulatory requirements (State Regulations, ERISA, URAC, NCQA).

Continuously review and remain informed of all ERISA, Non-ERISA, and/or state regulatory requirements and updates impacting the initial 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.

Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Pharmacist licenseCommercial prior authorization auditingERISA regulations knowledgeState regulatory complianceMicrosoft ExcelCompliance experienceURAC familiarityNCQA familiarityProblem-solving abilities

Required

Active, unrestricted, pharmacist license required

2+ years commercial initial prior authorization and/or appeals audit experience required

Extensive knowledge of how to operationalize Non-ERISA Commercial Fully Insured/Self-Funded/Exchange state-regulated prior authorization 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