Department

Job Title

Capital Rx is redefining the way prescriptions are priced and administered in the U.S. Capital Rx unlocks the pharmacy supply chain and reduces prescription costs for employer groups. By establishing a competitive marketplace for drug pricing, Capital Rx focuses its resources on deploying actionable strategies that improve plan performance and patient outcomes. The company's commitment to innovation, technology, and service is why Capital Rx is the fastest-growing pharmacy benefit manager in America.

Clinical

Quality Assurance Pharmacist - Medicare

Position Summary:

The Medicare QA Pharmacist will perform routine auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of Medicare coverage requests and appeals. The Medicare QA Pharmacist will utilize a strong comprehension of Centers for Medicare & Medicaid Services (CMS) guidance and regulatory requirements to ensure success in annual reporting (CDR, ODR), program audits (CDAG & ODAG), and ad hoc audits.

Position Responsibilities:

• Complete monthly coverage determination, organization determination, and appeals performance and process audits in alignment with CMS regulations and best practices.
• Create and maintain progress reports and audit results in accordance with regulatory requirements and internal processes.
• Present audit results to leadership in a timely manner to address issues and ensure adherence to departmental procedures and regulatory requirements (CMS, URAC, NCQA).
• Continuously review and remain informed of all CMS regulatory requirements and updates impacting the coverage request and appeals processes.
• Respond to inquiries from internal and external stakeholders regarding quality assurance processes, audit results, and compliance policies and procedures.
• Work independently and with team members as warranted by audit assignment.
• Assist in designing and implementing audit tools and programs, creating QA scorecards and guides in collaboration with all department stakeholders.
• Provide ongoing performance feedback, to team leads to ensure consistent performance.
• Assist management in identifying, evaluating, and mitigating operational, and compliance risks.
• Work in collaboration with operational leaders to identify training opportunities and recommend improvements to Work Instructions, Job Aids, and Policy and Procedures to improve performance.

Minimum Qualifications:

• Active, unrestricted, pharmacist license required
• 2+ years Medicare coverage determination, organization determination, and/or appeals audit experience required
• Extensive knowledge of how to operationalize Medicare requirements
• Strong oral and written communication skills required
• Intermediate to advanced Microsoft Excel skills required
• Possess strong analytical skills, attention to detail, quantitative, and problem-solving abilities
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven work environment
• Ability to multi-task and collaborate in a team with shifting priorities

Preferred Qualifications:

• CMS program audit experience
• Familiarity/experience with URAC and NCQA regulatory requirements
• 1+ years of compliance or regulatory experience at a PBM or health plan