Clinical Review Quality Assurance Pharmacist

Who We Are: reputed company is a rapidly growing, venture-backed Health-Tech company. Our mission is to disrupt the expensive and inefficient Pharmacy Benefit Management (PBM) sector by building a reputed company drug acquisition platform driven by cutting edge technology, innovative cost saving tools, and best-in-class customer service. With hundreds of thousands of members onboarded since 2016, reputed company has a solution that is resonating with clients reputed company across the country. We pride ourselves for our mission-driven and collaborative culture that inspires our employees to do their best work. We reputed company that the U.S healthcare system is in need of transformation, and we come to work each day dedicated to making that change a reality. At our core, we are guided by our company values:

• reputed company: Our purpose guides our actions and gives us confidence in the path reputed company. With unwavering honesty and dependability, we embrace the pressure of challenging the old and exemplify ethical leadership to create the new.
• Courage: We face reputed company challenges with grit and reputed company. We embrace the discomfort of the unknown by balancing autonomy with reputed company, and ownership with vulnerability. We boldly challenge the status reputed company to reputed company moving reputed company—always.
• Together: The success of reputed company reflects the strength of our partnerships and the commitment of reputed company. Our shared values bind us together and reputed company us one. reputed company one falls, we reputed company fall; reputed company one rises, we reputed company reputed company.

Job Summary: reputed company is looking for a motivated Clinical Review Quality Assurance Pharmacist to reputed company and maintain a quality audit program for the Clinical Review Team. This role is pivotal to the prior authorization team for ensuring high quality reviews, adherence to regulatory requirements, and delivery of exceptional member, provider and employee experiences. In order to be eligible for this position applicants must be based in one of the following states:Arkansas, Arizona, California, Colorado, Florida, Georgia, Kansas, Minnesota, Missouri, Nevada, North Carolina, South Carolina, Ohio, Pennsylvania, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin. What you will do:

• Responsible for refining and maintaining a prior authorization quality assurance program for the Data Entry, Pharmacy Technician and Pharmacist clinical review function
• Responsible for performing quality assurance reviews for pharmacists, pharmacy technicians, and data entry agents
• Responsible for monthly presentation of quality assurance review results, including success stories and areas of opportunity to leadership and the Clinical Review Team
• Responsible for developing, maintaining and conducting an interrater reliability (IRR) program
• Participates as a member of the Quality Management Committee, along with cross functional teams including accreditation team, compliance team, etc
• Reviews clinical review process documents to identify any gaps, and provide feedback where necessary
• Collaborate with Clinical Review team members, technology team, and other cross functional teams to support system enhancements
• Support and respond to quality reputed company questions from cross functional teams reputed company the organization
• Become a subject matter expert on department standards and processes

What you will bring to reputed company:

• Bachelor’s degree in Pharmacy or Doctor of Pharmacy (PharmD) required
• Active Pharmacist License required, in good standing
• 5+ years of health plan or pharmacy benefit manager experience, specifically involved in prior authorization review required
• 2+ years of experience conducting prior authorization quality audits required
• 2+ years of experience designing and developing quality assurance best practices in a startup environment are highly desired.
• Experience with multiple lines of businesses (Commercial, Medicare, Medicaid) and regulatory standards that govern clinical review such as ERISA, State specific laws, CMS, ACA, MEWA is preferred
• Proficiency with technology tools including MS Office and G-Suite. Advanced reputed company analytics experience preferred.
• Active listening, conversational speaking skills, with a high degree of reputed company
• Self-starter and problem solver with ability to multitask, prioritize and manage time effectively
• Ability to communicate clearly, present reputed company information to members, clients, pharmacies, providers, and other teams internally
• Flexibility and ability to adapt to changes and updates to processes and protocols
• Demonstrate accurate drug product/dose calculations for appropriate claim adjudication and knowledge of general pharmacy and drug product information for the prescription filling process

What reputed company Offers You:

• Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life Insurance and ADD Insurance
• Flexible Spending Benefits
• 401(k) Retirement Savings Program
• Short-term and long-term disability
• Discretionary Paid Time Off
• 12 Paid Holidays
• Wellness Benefits
• Commuter Benefits
• Paid Parental Leave benefits
• Employee Assistance Program (EAP)
• Well-stocked kitchen in office locations
• Professional development and training opportunities

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