Specialist, Claims Quality Assurance

Navitus Health Solutions, LLC

3d•Remote

About The Position

Due to growth, we are adding a Claims Quality Assurance Specialist to our team. The Claims Quality Assurance Specialist ensures the accuracy and integrity of pharmacy benefit configurations through comprehensive audit and testing activities. This role performs recurring monthly quality validations for assigned clients, including test preparation, scenario design, adjudication testing, and detailed result analysis across multiple environments. The Specialist applies expertise in diverse plan designs and benefit structures across Commercial, Exchange, Medicaid, and Medicare Part D lines of business while collaborating closely with cross functional teams. The role requires strong analytical skills, attention to detail, adaptability to ongoing system and industry changes, and occasional after hours or weekend support based on testing demands. Is this you? Find out more below!

Requirements

Bachelor’s degree or equivalent work experience is required.
5+ years of experience in quality assurance, benefit configuration, or data validation roles within a pharmacy benefit management (PBM) or similar payer environment required.
Intermediate proficiency required in Microsoft Office (Excel, Word, PowerPoint), QlikView/Qlik Sense or comparable reporting tools, formulary management applications, request management platforms (ConnectUs, Service Desk, Jira, ServiceNow), and PBM adjudication or configuration systems (e.g., Navi ClaimRx).
Participate in, adhere to, and support compliance program objectives.
The ability to consistently interact cooperatively and respectfully with other employees.

Nice To Haves

Pharmacy Technician License or National Certification preferred.
Experience supporting clients in all lines of business of varying size and complexity preferred.
Prior experience with data analysis, defect tracking, or root cause analysis within a healthcare environment preferred.

Responsibilities

Execute monthly quality assurance testing cycles, including client group selection, high utilization drug identification, test member preparation, adjudication file execution, results import, analysis, and month over month comparison.
Validate adjudication results against plan grids, formularies, configuration documents, and other sources of truth; prepare QA deliverables and submit discrepancies for resolution.
Design comprehensive test scenarios using live claim sampling, client issue history, and financially impactful drug categories to ensure adequate coverage.
Develop and apply working knowledge of Navitus audit methodologies and end to end pharmacy benefit workflows to identify quality risks and downstream impacts.
Identify, document, track, and retest defects as fixes are applied; support root cause analysis and resolution efforts.
Perform peer reviews and quality checks to ensure adherence to audit criteria, validation standards, and business rules.
Utilize QA and workflow tools (e.g., Qlik Sense, RxFlex, FBMS) to troubleshoot and resolve moderately complex adjudication and configuration issues.
Maintain an intermediate understanding of adjudication systems, testing environments, and quality assurance methodologies.
Participate in process improvement initiatives, documentation updates, training material development, automation efforts, and standardization activities.
Other duties as assigned.