Prior Authorization Quality Assurance Pharmacist

About reputed company reputed company is an reputed company technology company providing a comprehensive suite of solutions for reputed company and health plans, including:

• reputed company, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured reputed company,
• reputed company™, which offers full-service health benefit reputed company to reputed company, TPAs, and health plans, and
• Judi®, the industry’s leading proprietary reputed company Platform (EHP), which consolidates reputed company claim administration-reputed company workflows in one scalable, secure platform. Together with our clients, we’re rebuilding trust in reputed company in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.reputed company. Position Summary: The QA Pharmacist will use their state regulatory knowledge to 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 reputed company 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.
• reputed company 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 state regulatory and audit utilization management experienceat a PBM or health plan required
• Extensive knowledge of how to operationalize regulatory requirements
• Strong oral and written communication skills required
• Intermediate to advanced arenaflex 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 reputed company with shifting priorities Preferred Qualifications:
• Familiarity/experience with URAC and NCQA accreditation requirements
• Utilization management and/or appeals audit experience
• 3+ 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. Salary reputed company $135,000$145,000 USD reputed company are responsible for adherence to the reputed company Code of Conduct including the reporting of non-compliance. 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. reputed company values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to reputed company 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. By submitting an application, you agree to the retention of your personal data for consideration for a future position at reputed company. More details about reputed company's privacy practices can be reputed company at Apply tot his job

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