Clinical QA Specialist

ESSENTIAL DUTIES AND RESPONSIBILITIES Included but not limited to the following:

ï Execute QA-related tasks and processes in the Business QA department.
ï Provide Specific attention to clinical changes for government programs.
ï Review and validate that rules and utilization management along with clinical edits are programmed against
clinical policies accurately.
ï Write reports that will produce accurate information needed to validate that clinical changes are accurate.
ï Review all material at hand to determine if benefit changes match requests from the client.
ï Provide feedback to multiple departments on benefit configuration supporting clinical requests.
ï Work with various departments as needed to have plans updated to satisfy requested changes.
ï Perform pre and post implementation testing on benefit set up to ensure claims process accurately.
ï Document and track testing procedures for new functionality.
ï Make presentations to your peers as a department learning tool.
ï Miscellaneous duties as requested

QUALIFICATIONS AND REQUIREMENTS:

ï Certified Pharmacy Technician with at least 3 years experience required.
ï Strong knowledge of pharmacy terminology and medication management to interpret clinical guidelines.
ï Quality Control in a HealthPlan setting is preferred.
ï Experience in testing system applications and reading results highly desired
ï Ability to perform data audits using tools like Excel or SQL.
ï Clear concise written and verbal communication skills a plus.
ï Ability to multi-taks and adapt to changes as items are reprioritized.
ï Familiarity with regulatory or state specific clinical regulations governing pharmacy benefits.
ï Knowledge of R&R Reports Works a plus.

PHYSICAL DEMANDS
ï 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.

ProCareRx is an Equal Opportunity Employer.

Required Experience:

IC