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 processesRequirements:• 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 processBenefits:• 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