Position Summary:

The Medicare QA Pharmacist will perform routine auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of Medicare coverage requests and appeals. The Medicare QA Pharmacist will utilize a strong comprehension of Centers for Medicare & Medicaid Services (CMS) guidance and regulatory requirements to ensure success in annual reporting (CDR, ODR), program audits (CDAG & ODAG), and ad hoc audits.

Position Responsibilities:

• 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.

Minimum Qualifications:

• 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

Preferred Qualifications:

• CMS program audit experience
• Familiarity/experience with URAC and NCQA regulatory requirements
• 1+ years of compliance or regulatory experience at a PBM or health plan