Pharmacy Quality Assurance Analyst

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. Evaluate current policies and procedures against CMS/NCQA requirements; identify gaps and recommend improvements .

Posted 9/22/2026full-timeRemote • Illinois • United StatesMid-LevelSenior💰 $80,000 - $90,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in evaluating and improving policies and procedures to meet CMS and NCQA requirements, alongside strong analytical skills for data analysis and problem-solving. Proficient in managing audits, training, and compliance processes within the healthcare sector.

Highest-signal resume keywords

CMS ComplianceNCQA RequirementsSQL Data QueriesPharmacy Internal AuditsProject Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalysisReport GenerationBusiness IntelligenceObject-Oriented AnalysisCalculating PercentagesInterpreting GraphsCorrective Action PlansPharmacy OperationsQuality ControlTraining Development

Soft Skills

Analytical SkillsProblem-SolvingCommunication SkillsTeamworkAdaptability

Tools & Technologies

SalesforceCVS Caremark PBM Reports

Certifications & Qualifications

Registered Pharmacy Technician Certification

Industry Keywords

HealthcareCMSNCQAPharmacy Benefit ManagementAudit Processes

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

Preferred: Registered Pharmacy Technician & Certification
Bachelor’s degree or 5+ years of healthcare experience
Strong analytical, mathematical, and problem-solving skills
Experience with SQL data queries and report generation is a plus
Excellent communication and interpersonal skills
Bilingual (English/Spanish) preferred
Experience with CVS Caremark PBM Reports
Business intelligence and comparative analysis
Project management and technical writing
Ability to manage high-volume workloads professionally
Strong teamwork and adaptability
Proficiency in business modeling and object-oriented analysis
Comfortable working flexible schedules (nights, weekends, holidays)
Proficient in calculating percentages, ratios, and interpreting graphs
Able to solve practical problems and interpret varied instructions