Pharmacy Quality Assurance Analyst

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

📋 Description

• Assess existing policies and procedures in relation to CMS/NCQA standards; identify deficiencies and suggest enhancements.

• Ensure that system upgrades and implementations align with business and regulatory requirements.

• Create and present training on new CMS/NCQA standards; administer assessments as necessary.

• Carry out internal and delegated audits; oversee pharmacy operations and propose corrective measures.

• Direct recovery initiatives for COB, ESRD, Hospice, PDEs, LICs, P2P, and associated processes.

• Examine claims and utilization data to confirm the presence of quality controls.

• Reconcile vendor bills and address member/provider inquiries arising from Salesforce cases.

• Assist in PDE management and the resolution of errors.

• Supervise FIR and COB backend reconciliation activities.

• Conduct monthly quality assessments for marketing collateral (both print and digital).

• Execute monthly audits and evaluations across pharmacy divisions.

• Provide suggestions to enhance system and process effectiveness.

• Coordinate audits of external entities and vendors.

• Assist in CMS Financial, Operational, and NCQA audits.

• Preserve audit samples and track performance metrics.

• Oversee yearly updates to policies, procedures, and training documentation.

• Lead the implementation of the Pharmacy Internal Audit Plan, covering FIR/Nx Rejects, PDE Monitoring, MTM, Formulary Administration, and Claims Processing.

• Maintain and implement Corrective Action Plans and Compliance Issues Logs.

• Facilitate monthly internal compliance meetings.

⛳️ Requirements

• Preferred: Registered Pharmacy Technician & Certification.

• Bachelor’s degree or a minimum of 5 years of healthcare experience.

• Strong analytical, mathematical, and problem-solving abilities.

• Experience with SQL data queries and report generation is advantageous.

• Exceptional communication and interpersonal skills.

• Bilingual (English/Spanish) is preferred.

• Familiarity with CVS Caremark PBM Reports.

• Expertise in business intelligence and comparative analysis.

• Skills in project management and technical writing.

• Ability to handle high-volume workloads in a professional manner.

• Strong teamwork skills and adaptability.

• Proficient in business modeling and object-oriented analysis.

• Willingness to work flexible hours (nights, weekends, holidays).

• Competent in calculating percentages, ratios, and interpreting graphs.

• Capable of solving practical problems and interpreting diverse instructions.

🏝️ Benefits

• Competitive salary and benefits package.

• Opportunities for professional development and advancement.

• Supportive work environment with a focus on collaboration.