Quality Assurance, QA Pharmacist

Job Description: • 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. Requirements: • 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 Benefits: