Pharmacy QA Specialist

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Dane Street

SiteLinkedInTodas as Vagas

51 - 200 funcionários

⚕️ Seguro de Saúde

📋 Conformidade

🏛️ Governo

Healthcare Insurance • Compliance • Government

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

• The Pharmacy QA Specialist plays a critical role in the pharmacy review process, supporting PBM clients by ensuring the accuracy, completeness, and quality of pharmacy-related determinations and documentation. • This role is responsible for coordinating with clients, pharmacists, and internal teams to ensure that all reviews are completed in accordance with client requirements, regulatory standards, and turnaround time expectations. • In addition to standard QA responsibilities, provides subject matter expertise related to pharmacy benefits, medication reviews, and PBM processes, and serves as a resource for non-pharmacy QA staff on medication-related questions. • Provide regular status updates to PBM clients regarding case progress and completion timelines. • Evaluate the quality and completeness of pharmacy reviews to ensure alignment with client policies, formularies, and regulatory requirements. • Ensure that determinations are supported by appropriate clinical and/or formulary rationale. • Clarify ambiguous or incomplete requests with clients. • Distribute final determinations in accordance with client-specific requirements. • Manage and execute clarification and addendum requests from clients. • Follow up with clients for missing or incomplete information necessary to complete reviews. • Work directly with pharmacists and/or reviewers to ensure all client questions are addressed accurately. • Ensure determinations are supported by appropriate clinical guidelines, formulary rules, and PBM policies. • Conduct follow-ups to ensure timely completion of reviews. • Provide feedback to pharmacists regarding documentation quality and completeness. • Issue clarification requests when additional rationale or information is required. • Ensure final documentation is complete, approved, and properly attributed prior to release. • Review each case for accuracy, including medication details, dosing, clinical rationale, and documentation quality. • Ensure compliance with applicable state, federal, and client-specific PBM requirements. • Verify adherence to client-specific workflows, including prior authorization, appeals, and exception processes. • Ensure all special handling instructions are followed prior to case release. • Reliable high-speed internet connection. • Ability to maintain a secure and uninterrupted work environment.

🎯 Requisitos

• Education / Credentials • - Active Pharmacy Technician Certification (CPhT or equivalent) required • - State Pharmacy Technician registration/licensure (if applicable) required • - Associate or Bachelor’s degree preferred • Job Relevant Experience • - Experience in a PBM, managed care, pharmacy operations, or healthcare setting required • - Experience with prior authorizations, formulary review, or medication review processes required • Job Related Skills / Competencies • - Strong understanding of pharmacy terminology, medications, and PBM workflows • - Ability to interpret clinical guidelines, formularies, and coverage criteria • - Excellent communication skills (written and verbal) • - 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

🏖️ Benefícios

• Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace. • ABOUT DANE STREET: • A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.