Call Center Speech Analyst
General Dynamics Information Technology
Cloud
Quality Assurance Pharmacist – Medicare
Capital Rx
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $135,000 - $145,000 per year
Job Level
JuniorMid-Level
Tech Stack
Cloud
About the role
- Perform routine auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of Medicare coverage requests and appeals
- Complete monthly coverage determination, organization determination, and appeals performance and process audits in alignment with CMS regulations and best practices
- Create and maintain progress reports and audit results in accordance with regulatory requirements and internal processes
- Present audit results to leadership in a timely manner to address issues and ensure adherence to departmental procedures and regulatory requirements (CMS, URAC, NCQA)
- Continuously review and remain informed of all CMS regulatory 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
Requirements
- Active, unrestricted, pharmacist license required
- 2+ years Medicare coverage determination, organization determination, and/or appeals audit experience required
- Extensive knowledge of how to operationalize Medicare 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
- CMS program audit experience (preferred)
- Familiarity/experience with URAC and NCQA regulatory requirements (preferred)
- 1+ years of compliance or regulatory experience at a PBM or health plan (preferred)
