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QA Engineer

• Evaluate current policies and procedures against CMS/NCQA requirements; identify gaps and recommend improvements
• Ensure system enhancements and implementations meet business and regulatory needs
• Develop and deliver training on new CMS/NCQA requirements; administer exams as needed
• Conduct internal and delegated audits; monitor pharmacy operations and recommend corrective actions
• Lead recovery efforts for COB, ESRD, Hospice, PDEs, LICs, P2P, and related processes
• Analyze claims and utilization data to ensure quality controls are in place
• Reconcile vendor invoices and resolve member/provider issues from Salesforce cases
• Support PDE management and error resolution processes
• Oversee FIR and COB backend reconciliation activities
• Manage monthly quality checks for marketing materials (print and web)
• Perform monthly audits and exams across pharmacy units
• Present recommendations to improve system and process efficiency
• Coordinate audits of delegated entities and vendors
• Support CMS Financial, Operational, and NCQA audits
• Maintain audit samples and monitor performance metrics
• Manage annual updates to policies, procedures, and training logs
• Lead execution of the Pharmacy Internal Audit Plan, including FIR/Nx Rejects, PDE Monitoring, MTM, Formulary Administration, and Claims Processing
• Maintain and execute Corrective Action Plans and Compliance Issues Logs
• Facilitate monthly internal compliance meetings

Pharmacy Quality Assurance Analyst