Clinical QA Specialist

ProCare Rx•Gainesville, GA

5d•Onsite

About The Position

The Clinical QA Specialist will execute QA-related tasks and processes within the Business QA department, with a specific focus on clinical changes for government programs. This role involves reviewing and validating the accurate programming of rules, utilization management, and clinical edits against clinical policies. The specialist will also be responsible for writing reports to validate the accuracy of clinical changes, reviewing materials to ensure benefit changes align with client requests, and providing feedback to various departments on benefit configuration to support clinical requests. Collaboration with different departments will be necessary to update plans according to requested changes. Additionally, the role includes performing pre and post-implementation testing of benefit setups to ensure accurate claims processing, documenting and tracking testing procedures for new functionality, and making presentations to peers as a learning tool.

Requirements

Certified Pharmacy Technician with at least 3 years experience required.
Strong knowledge of pharmacy terminology and medication management to interpret clinical guidelines.
Ability to perform data audits using tools like Excel or SQL.
Ability to multi-task and adapt to changes as items are reprioritized.
Familiarity with regulatory or state specific clinical regulations governing pharmacy benefits.

Nice To Haves

Quality Control in a HealthPlan setting is preferred.
Experience in testing system applications and reading results highly desired.
Clear concise written and verbal communication skills a plus.
Knowledge of R&R Reports Works a plus.

Responsibilities

Execute QA-related tasks and processes in the Business QA department.
Provide specific attention to clinical changes for government programs.
Review and validate that rules and utilization management along with clinical edits are programmed against clinical policies accurately.
Write reports that will produce accurate information needed to validate that clinical changes are accurate.
Review all material at hand to determine if benefit changes match requests from the client.
Provide feedback to multiple departments on benefit configuration supporting clinical requests.
Work with various departments as needed to have plans updated to satisfy requested changes.
Perform pre and post implementation testing on benefit set up to ensure claims process accurately.
Document and track testing procedures for new functionality.
Make presentations to your peers as a department learning tool.
Miscellaneous duties as requested