Pharmacy QA Specialist

🕒 6 dias atrás

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Dane Street

SiteLinkedInTodas as Vagas

51 - 200 funcionários

🏥 Saúde

💼 Consultoria

⚖️ Jurídico

Healthcare • Consulting • Legal

A Dane Street é líder nacional em Exames e Revisões Médicas Independentes, fornecendo Exames Médicos Independentes (IMEs), Revisões por Pares e outros laudos médicos de forma objetiva, em conformidade e dentro dos prazos. Com uma ampla rede de mais de 16. 000 médicos, a empresa oferece serviços em 25. 000 localidades e 100 especialidades, incluindo sinistros de compensação trabalhista (Workers’ Compensation), automóvel, responsabilidade civil (Liability) e incapacidade (Disability). A Dane Street atende seguradoras, Third-Party Administrators (TPAs), organizações de Managed Care e órgãos federais/estaduais com análises médicas especializadas, ajudando-os a tomar decisões precisas. A empresa é reconhecida pela qualidade, prazos de entrega ágeis e processos eficientes, tendo conquistado credenciais como a Acreditação da NCQA em Utilization Management e a certificação Great Place to Work.

Descrição

• Coordinate with PBM clients, pharmacists, reviewers, and internal teams to complete pharmacy reviews • Provide clients with status updates on case progress and completion timelines • Evaluate pharmacy reviews for quality, completeness, client-policy, formulary, and regulatory alignment • Ensure determinations include appropriate clinical and/or formulary rationale • Clarify ambiguous or incomplete client requests and follow up for missing information • Distribute final determinations according to client-specific requirements • Manage clarification and addendum requests from clients • Work directly with pharmacists and reviewers to address client questions accurately • Provide feedback to pharmacists on documentation quality and completeness • Review cases for medication details, dosing, clinical rationale, and documentation quality • Ensure compliance with state, federal, and client-specific PBM requirements • Verify adherence to prior authorization, appeals, and exception workflows • Ensure special handling instructions are followed before case release • Serve as a pharmacy subject matter expert and resource for non-pharmacy QA staff

🎯 Requisitos

• Active Pharmacy Technician Certification (CPhT or equivalent) required • State Pharmacy Technician registration/licensure, if applicable, required • Experience in a PBM, managed care, pharmacy operations, or healthcare setting required • Experience with prior authorizations, formulary review, or medication review processes required • Strong understanding of pharmacy terminology, medications, and PBM workflows • Ability to interpret clinical guidelines, formularies, and coverage criteria • Excellent written and verbal communication skills • Strong attention to detail and quality standards • Critical thinking and problem-solving abilities • Ability to manage time effectively and meet strict deadlines • Proficiency in computer systems and documentation platforms • Prolonged periods of sitting and computer work • Ability to perform standard office functions • Reliable high-speed internet connection • Ability to maintain a secure and uninterrupted work environment

🏖️ Benefícios

• Medical, dental, and vision coverage for employees and their families • Voluntary life insurance for employees, spouses, and children • Voluntary hospital indemnity, critical illness, accident indemnity, and pet insurance plans • Basic life insurance at no cost • Short-term disability coverage at no cost • Long-term disability coverage at no cost • Generous paid time off policy • 401k plan with company match • Apple equipment for remote workspace • Media stipend for remote workspace