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Location: Remote (For Non-Local) or Hybrid (Local to NYC area)

Position Summary:

The Commercial QA Pharmacist will perform routine auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of commercial prior authorization requests and appeals. The Commercial QA Pharmacist will utilize a strong comprehension of applicable state law requirements and Employee Retirement Income Security Act (ERISA) regulations to ensure plan compliance and success in annual reporting, state audits, and ad hoc audits.

Position Responsibilities:

• Act as a subject matter expert for Commercial Non-ERISA Fully Insured, Self-Funded, and Exchange Plans governed by state regulations.
• Complete monthly initial prior authorization and appeals performance and process audits in alignment with best practices and any applicable ERISA and state regulations.
• 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 (State Regulations, ERISA, URAC, NCQA).
• Continuously review and remain informed of all ERISA, Non-ERISA, and/or state regulatory requirements and updates impacting the initial 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.
• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance

Minimum Qualifications:

• Active, unrestricted, pharmacist license required
• 2+ years commercial initial prior authorization and/or appeals audit experience required
• Extensive knowledge of how to operationalize Non-ERISA Commercial Fully Insured/Self-Funded/Exchange state-regulated prior authorization 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:

• State regulatory audit experience (including but not limited to Texas Department of Insurance)
• Familiarity/experience with URAC and NCQA regulatory requirements
• 1+ years of compliance or regulatory experience at a PBM or health plan

Base Salary: $125,000 - $135,000

Visa Sponsorship: Capital Rx does not provide sponsorship to any candidates. This includes, but is not limited to those that require H1-B, TN, OPT, etc. Candidates must have authorization to work in the US at the time of application and throughout employment.

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp™, Capital Rx is executing its mission through the deployment of JUDI®, the company’s cloud-native enterprise health platform, and a Single-Ledger Model™, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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