Quality Control Specialist - Medicare Pharmacy Claims
About The Position
This role is responsible for reviewing Medicare pharmacy claims to ensure compliance with CMS requirements and prevent access-to-care issues. The Quality Control Specialist conducts regular audits to verify adherence to regulations, internal policies, and operational procedures, while maintaining thorough documentation to support potential CMS program audits. This role also identifies error trends and root causes, recommends process improvements, and contributes to updating job aids and procedures. As a key team member, the specialist is expected to drive improvements that enhance the accuracy, efficiency, and overall quality of Pharmacy Operations.
Requirements
- High school diploma or GED.
- 2 years business experience.
- A combination of college level education and experience will be considered.
- Clear and concise interpersonal, verbal and written communication skills to facilitate the learning process; coaching and mentoring skills.
- PC experience in Windows, Word, Excel, Access, and other business related/associated databases.
- Demonstrated analytical and organizational skills.
Nice To Haves
- Advanced Excel skills including vlook-ups, pivot tables.
- Practical experience of 1+ years providing oversight of Medicare pharmacy claims.
- 1-2 years pharmacy claims experience and/or managed care experience preferred.
- Knowledge of CMS Guidance of MAPD, Part D Plans, and EGWP.
- Experience with Audits preferred.
- Critical Thinker- able to analyze, interpret, explain, self-regulate, open-minded and problem solving mind set.
- Capable of explaining complex issues in a concise manner.
- CPhT preferred, but not required.
- SQL (Teradata) Knowledge preferred.
Responsibilities
- Reviewing Medicare pharmacy claims to ensure compliance with CMS requirements and prevent access-to-care issues.
- Conducting regular audits to verify adherence to regulations, internal policies, and operational procedures.
- Maintaining thorough documentation to support potential CMS program audits.
- Identifying error trends and root causes.
- Recommending process improvements.
- Contributing to updating job aids and procedures.
- Driving improvements that enhance the accuracy, efficiency, and overall quality of Pharmacy Operations.
Benefits
- health and wellness benefits
- 401(k) savings plan
- pension plan
- paid time off
- paid parental leave
- disability insurance
- supplemental life insurance
- employee assistance program
- paid holidays
- tuition reimbursement
- annual incentive bonus plan
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
