Pharmacy QA Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Collaborate with PBM clients, pharmacists, reviewers, and internal teams to finalize pharmacy reviews.

• Keep clients informed with updates regarding case status and timelines for completion.

• Assess pharmacy reviews for quality, thoroughness, alignment with client policies, formularies, and regulatory standards.

• Ensure that determinations are supported by appropriate clinical and/or formulary justifications.

• Address unclear or incomplete client requests and follow up for any missing information.

• Distribute final determinations according to the specific requirements of clients.

• Handle clarification and addendum requests from clients.

• Work closely with pharmacists and reviewers to accurately address client inquiries.

• Provide constructive feedback to pharmacists regarding the quality and completeness of documentation.

• Review cases for medication specifics, dosing, clinical justifications, and documentation quality.

• Ensure adherence to state, federal, and client-specific PBM regulations.

• Verify compliance with prior authorization, appeals, and exception processes.

• Ensure that special handling instructions are adhered to prior to case release.

• Act as a pharmacy subject matter expert and resource for non-pharmacy Quality Assurance staff.

⛳️ Requirements

• Active Pharmacy Technician Certification (CPhT or equivalent) is mandatory.

• State Pharmacy Technician registration/licensure, if applicable, is required.

• Experience in a Pharmacy Benefit Manager (PBM), managed care, pharmacy operations, or healthcare environment is essential.

• Background in prior authorizations, formulary reviews, or medication review processes is necessary.

• Strong knowledge of pharmacy terminology, medications, and PBM workflows is crucial.

• Ability to interpret clinical guidelines, formularies, and coverage criteria is required.

• Exceptional written and verbal communication skills are a must.

• High attention to detail and adherence to quality standards is essential.

• Strong critical thinking and problem-solving skills are necessary.

• Ability to effectively manage time and meet tight deadlines is required.

• Proficiency in computer systems and documentation platforms is necessary.

• Capability to work for extended periods at a computer.

• Ability to perform standard office functions is required.

• A reliable high-speed internet connection is necessary.

• Ability to maintain a secure and uninterrupted work environment is essential.

🏝️ Benefits

• Medical, dental, and vision insurance coverage for employees and their families.

• Voluntary life insurance options for employees, spouses, and children.

• Voluntary plans for hospital indemnity, critical illness, accident indemnity, and pet insurance.

• Basic life insurance provided at no cost.

• No-cost short-term disability coverage.

• No-cost long-term disability coverage.

• Generous paid time off policy.

• 401k plan with company matching contributions.

• Apple equipment provided for remote workspaces.

• Media stipend available for remote workspaces.