Clinical QA Specialist
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Overview
Job Description
ESSENTIAL DUTIES AND RESPONSIBILITIES Included but not limited to the following:
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
QUALIFICATIONS AND REQUIREMENTS:
Certified Pharmacy Technician with at least 3 years experience required.
Strong knowledge of pharmacy terminology and medication management to interpret clinical guidelines.
Quality Control in a HealthPlan setting is preferred.
Experience in testing system applications and reading results highly desired
Ability to perform data audits using tools like Excel or SQL.
Clear concise written and verbal communication skills a plus.
Ability to multi-taks and adapt to changes as items are reprioritized.
Familiarity with regulatory or state specific clinical regulations governing pharmacy benefits.
Knowledge of R&R Reports Works a plus.
PHYSICAL DEMANDS
Requires sitting, standing, and occasional light lifting.
This is a full-time position with benefits. Please visit our Contact Us/Opportunities page on our website for more information about our benefits list.
ProCareRx will never ask for a financial commitment from an applicant, as part of our recruitment process. All interviews are conducted in-person OR through video conference invitations from official company emails. For inquiries, please contact our official recruitment team at HumanResources@procarerx.com.
ProCareRx is an Equal Opportunity Employer.
Automate your job search with Sonara.
Submit 10x as many applications with less effort than one manual application.
