Prior Authorization Quality Assurance Pharmacist

About Judi Health

Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including:

• Capital Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers,

• Judi Health™, which offers full-service health benefit management solutions to employers, TPAs, and health plans, and

• Judi®, the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform.

Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.judi.health.

Position Summary:

The QA Pharmacist will use their state regulatory knowledge to perform routine auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of coverage requests and appeals. The QA Pharmacist will utilize a strong comprehension of regulatory requirements to ensure success in annual reporting, program audits, and ad hoc audits.

Position Responsibilities:

• Complete monthly utilization management and appeals performance and process audits in alignment with applicable regulations, accreditation standards, and best practices.

• Create and maintain progress reports and audit results in accordance with regulatory/accreditation requirements and internal processes.

• Present audit results to leadership in a timely manner to address issues and ensure adherence to departmental procedures and regulatory/accreditation requirements (CMS, URAC, NCQA).

• Continuously review and remain informed of all regulatory/accreditation 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 of state regulatory and audit utilization management experience at a PBM or health plan required

• Extensive knowledge of how to operationalize regulatory 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:

• Familiarity/experience with URAC and NCQA accreditation requirements

• Utilization management and/or appeals audit experience

• 3+ years of compliance or regulatory experience at a PBM or health plan

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

#LI-BC1

Salary Range
$135,000—$145,000 USD

All employees are responsible for adherence to the Capital Rx Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

Judi Health values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at https://www.judi.health/legal/privacy-policy.