Pharmacy QA Specialist

Dane Street, LLC

21h • Remote

About The Position

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, the Pharmacy QA Specialist 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.
Dane Street’s success relies on individual and team contributions every day. We care for our customers, each other, and Dane Street. All employees are expected to maintain a positive working environment that promotes client satisfaction and high-quality outcomes.

Requirements

• 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 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
• Reliable high-speed internet connection
• Ability to maintain a secure and uninterrupted work environment
• Prolonged periods of sitting and computer work
• Ability to perform standard office functions

Nice To Haves

• Associate or Bachelor’s degree preferred

Responsibilities

• 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

Benefits

• medical, dental, and vision coverage for you and your family
• voluntary life insurance options for you, your spouse, and your children
• hospital indemnity, critical illness, accident indemnity, and pet insurance plans
• basic life insurance, short-term disability, and long-term disability coverage at no cost
• generous paid time off policy
• 401k plan with a company match
• Apple equipment and a media stipend are provided for remote workspace

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree