Quality Assurance (QA) Pharmacist (Medtech)

TL;DR

Quality Assurance (QA) Pharmacist (Medtech): Performing routine auditing and monitoring of coverage requests and appeals to ensure regulatory compliance with an accent on state regulatory knowledge and PBM standards. Focus on managing annual reporting, conducting program audits, and mitigating operational risks within the US healthcare infrastructure.

Location: Remote (US)

Salary: $135,000 - $145,000 USD

Company

Enterprise health technology company providing comprehensive pharmacy benefit management (PBM) and health benefit management solutions for employers and health plans.

What you will do

• Conduct monthly utilization management and appeals performance audits in alignment with regulations and accreditation standards.
• Create and maintain progress reports and audit results for regulatory and internal requirements.
• Present audit results to leadership to ensure adherence to CMS, URAC, and NCQA standards.
• Design and implement audit tools, QA scorecards, and guides in collaboration with stakeholders.
• Provide ongoing performance feedback to team leads and recommend improvements to Work Instructions and Policies.
• Identify, evaluate, and mitigate operational and compliance risks.

Requirements

• Active, unrestricted pharmacist license required
• 2+ years of state regulatory and audit utilization management experience at a PBM or health plan
• Strong oral and written communication skills
• Intermediate to advanced Microsoft Excel skills
• Strong analytical, quantitative, and problem-solving abilities
• Ability to work independently in a remote, high-volume, metric-driven environment

Nice to have

• Familiarity or experience with URAC and NCQA accreditation requirements
• Specific utilization management and/or appeals audit experience
• 3+ years of compliance or regulatory experience at a PBM or health plan

Culture & Benefits

• Fully remote work arrangement
• Opportunity to rebuild trust in the U.S. healthcare infrastructure
• Commitment to a diverse and inclusive workplace
• Equal employment opportunity environment