Clinical Review QA Pharmacist

Job Description: • Responsible for refining and maintaining a prior authorization quality assurance program for the Data Entry, Pharmacy Technician and Pharmacist clinical review function • Responsible for performing quality assurance reviews for pharmacists, pharmacy technicians, and data entry agents • Responsible for monthly presentation of quality assurance review results, including success stories and areas of opportunity to leadership and the Clinical Review Team • Responsible for developing, maintaining and conducting an interrater reliability (IRR) program • Participates as a member of the Quality Management Committee, along with cross functional teams including accreditation team, compliance team, etc • Reviews clinical review process documents to identify any gaps, and provide feedback where necessary • Collaborate with Clinical Review team members, technology team, and other cross functional teams to support system enhancements • Support and respond to quality related questions from cross functional teams within the organization • Become a subject matter expert on department standards and processes Requirements: • Bachelor’s degree in Pharmacy or Doctor of Pharmacy (PharmD) required • Active Pharmacist License required, in good standing • 5+ years of health plan or pharmacy benefit manager experience, specifically involved in prior authorization review required • 2+ years of experience conducting prior authorization quality audits required • 2+ years of experience designing and developing quality assurance best practices in a startup environment are highly desired. • Experience with multiple lines of businesses (Commercial, Medicare, Medicaid) and regulatory standards that govern clinical review such as ERISA, State specific laws, CMS, ACA, MEWA is preferred • Proficiency with technology tools including MS Office and G-Suite. Advanced Excel analytics experience preferred. • Active listening, conversational speaking skills, with a high degree of empathy • Self-starter and problem solver with ability to multitask, prioritize and manage time effectively • Ability to communicate clearly, present complex information to members, clients, pharmacies, providers, and other teams internally • Flexibility and ability to adapt to changes and updates to processes and protocols • Demonstrate accurate drug product/dose calculations for appropriate claim adjudication and knowledge of general pharmacy and drug product information for the prescription filling process Benefits: • Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life Insurance and AD&D Insurance • Flexible Spending Benefits • 401(k) Retirement Savings Program • Short-term and long-term disability • Discretionary Paid Time Off • 12 Paid Holidays • Wellness Benefits • Commuter Benefits • Paid Parental Leave benefits • Employee Assistance Program (EAP) • Well-stocked kitchen in office locations • Professional development and training opportunities Apply tot his job Apply To this Job