Prior Authorization Quality Assurance Pharmacist Join to apply for the Prior Authorization Quality Assurance Pharmacist role at Capital Rx
Prior Authorization Quality Assurance Pharmacist Join to apply for the Prior Authorization Quality Assurance Pharmacist role at Capital Rx
Position Summary
The QA Pharmacist will perform 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 success in annual reporting, program audits, and ad hoc audits.
Position Summary
The QA Pharmacist will perform 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 success in annual reporting, program audits, and ad hoc 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 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.
Minimum Qualifications
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 Qualifications
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
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 Range
$135,000—$145,000 USD
About Capital Rx
Capital Rx is a health technology company providing claim administration and technology solutions for carriers, health plans, TPAs, employer groups, and government entities. As a public benefit corporation, Capital Rx is executing its mission to materially reduce healthcare costs as a full-service PBM and through the deployment of Judi, the company’s cloud-native enterprise health platform. Judi connects every aspect of the healthcare ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of benefits and rebuilding trust in healthcare.
Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, 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.
Seniority level Seniority level Entry level
Employment type Employment type Full-time
Job function Job function Health Care Provider
Industries Hospitals and Health Care
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