Claims Quality Assurance Specialist
Job Description:
• Execute monthly quality assurance testing cycles, including client group selection, high utilization drug identification, test member preparation, adjudication file execution, results import, analysis, and month over month comparison.
• Validate adjudication results against plan grids, formularies, configuration documents, and other sources of truth; prepare QA deliverables and submit discrepancies for resolution.
• Design comprehensive test scenarios using live claim sampling, client issue history, and financially impactful drug categories to ensure adequate coverage.
• Develop and apply working knowledge of Navitus audit methodologies and end to end pharmacy benefit workflows to identify quality risks and downstream impacts.
• Identify, document, track, and retest defects as fixes are applied; support root cause analysis and resolution efforts.
• Perform peer reviews and quality checks to ensure adherence to audit criteria, validation standards, and business rules.
• Utilize QA and workflow tools (e.g., Qlik Sense, RxFlex, FBMS) to troubleshoot and resolve moderately complex adjudication and configuration issues.
• Maintain an intermediate understanding of adjudication systems, testing environments, and quality assurance methodologies.
• Participate in process improvement initiatives, documentation updates, training material development, automation efforts, and standardization activities.
• Other duties as assigned.
Requirements:
• Bachelor’s degree or equivalent work experience is required.
• Pharmacy Technician License or National Certification preferred.
• 5+ years of experience in quality assurance, benefit configuration, or data validation roles within a pharmacy benefit management (PBM) or similar payer environment required.
• Experience supporting clients in all lines of business of varying size and complexity preferred.
• Intermediate proficiency required in Microsoft Office (Excel, Word, PowerPoint), QlikView/Qlik Sense or comparable reporting tools, formulary management applications, request management platforms (ConnectUs, Service Desk, Jira, ServiceNow), and PBM adjudication or configuration systems (e.g., Navi ClaimRx).
• Prior experience with data analysis, defect tracking, or root cause analysis within a healthcare environment preferred.
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees.
Benefits:
• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!
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• Execute monthly quality assurance testing cycles, including client group selection, high utilization drug identification, test member preparation, adjudication file execution, results import, analysis, and month over month comparison.
• Validate adjudication results against plan grids, formularies, configuration documents, and other sources of truth; prepare QA deliverables and submit discrepancies for resolution.
• Design comprehensive test scenarios using live claim sampling, client issue history, and financially impactful drug categories to ensure adequate coverage.
• Develop and apply working knowledge of Navitus audit methodologies and end to end pharmacy benefit workflows to identify quality risks and downstream impacts.
• Identify, document, track, and retest defects as fixes are applied; support root cause analysis and resolution efforts.
• Perform peer reviews and quality checks to ensure adherence to audit criteria, validation standards, and business rules.
• Utilize QA and workflow tools (e.g., Qlik Sense, RxFlex, FBMS) to troubleshoot and resolve moderately complex adjudication and configuration issues.
• Maintain an intermediate understanding of adjudication systems, testing environments, and quality assurance methodologies.
• Participate in process improvement initiatives, documentation updates, training material development, automation efforts, and standardization activities.
• Other duties as assigned.
Requirements:
• Bachelor’s degree or equivalent work experience is required.
• Pharmacy Technician License or National Certification preferred.
• 5+ years of experience in quality assurance, benefit configuration, or data validation roles within a pharmacy benefit management (PBM) or similar payer environment required.
• Experience supporting clients in all lines of business of varying size and complexity preferred.
• Intermediate proficiency required in Microsoft Office (Excel, Word, PowerPoint), QlikView/Qlik Sense or comparable reporting tools, formulary management applications, request management platforms (ConnectUs, Service Desk, Jira, ServiceNow), and PBM adjudication or configuration systems (e.g., Navi ClaimRx).
• Prior experience with data analysis, defect tracking, or root cause analysis within a healthcare environment preferred.
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees.
Benefits:
• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!
Apply tot his job
Apply To this Job