Pharmacy Quality Assurance Analyst

Job not on LinkedIn

🕒 September 22

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $80k - $90k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔧 QA Engineer (Quality Assurance)

👻 Ghost score 7%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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📋 Description

• Evaluate current policies and procedures against CMS/NCQA requirements; identify gaps and recommend improvements • Ensure system enhancements and implementations meet business and regulatory needs • Develop and deliver training on new CMS/NCQA requirements; administer exams as needed • Conduct internal and delegated audits; monitor pharmacy operations and recommend corrective actions • Lead recovery efforts for COB, ESRD, Hospice, PDEs, LICs, P2P, and related processes • Analyze claims and utilization data to ensure quality controls are in place • Reconcile vendor invoices and resolve member/provider issues from Salesforce cases • Support PDE management and error resolution processes • Oversee FIR and COB backend reconciliation activities • Manage monthly quality checks for marketing materials (print and web) • Perform monthly audits and exams across pharmacy units • Present recommendations to improve system and process efficiency • Coordinate audits of delegated entities and vendors • Support CMS Financial, Operational, and NCQA audits • Maintain audit samples and monitor performance metrics • Manage annual updates to policies, procedures, and training logs • Lead execution of the Pharmacy Internal Audit Plan, including FIR/Nx Rejects, PDE Monitoring, MTM, Formulary Administration, and Claims Processing • Maintain and execute Corrective Action Plans and Compliance Issues Logs • Facilitate monthly internal compliance meetings

🎯 Requirements

• Preferred: Registered Pharmacy Technician & Certification • Bachelor’s degree or 5+ years of healthcare experience • Strong analytical, mathematical, and problem-solving skills • Experience with SQL data queries and report generation is a plus • Excellent communication and interpersonal skills • Bilingual (English/Spanish) preferred • Experience with CVS Caremark PBM Reports • Business intelligence and comparative analysis • Project management and technical writing • Ability to manage high-volume workloads professionally • Strong teamwork and adaptability • Proficiency in business modeling and object-oriented analysis • Comfortable working flexible schedules (nights, weekends, holidays) • Proficient in calculating percentages, ratios, and interpreting graphs • Able to solve practical problems and interpret varied instructions

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