QA Pharmacist

About Judi Health and Capital Rx

Judi Health is an enterprise health technology company that offers a comprehensive suite of solutions, including Capital Rx, a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers.

We are rebuilding trust in healthcare in the U.S. by deploying the infrastructure needed for the care we deserve. Learn more at www.judi.health.

Position Summary

The QA Pharmacist will leverage state regulatory expertise to perform routine audits and monitoring to ensure quality, accuracy, and regulatory compliance of coverage requests and appeals. The role involves annual reporting, program audits, and ad hoc audits in line with regulatory requirements.

Position Responsibilities

• Perform monthly utilization management and appeals audits following regulations and best practices.
• Create and maintain progress reports and audit results in compliance with CMS, URAC, and NCQA standards.
• Present audit results to leadership to address issues and ensure adherence to policies.
• Stay current on regulatory and accreditation updates impacting coverage and appeals processes.
• Respond to inquiries from stakeholders regarding quality assurance processes and outcomes.
• Collaborate to design and implement audit tools, QA scorecards, and guides.
• Provide performance feedback and assist management in identifying compliance risks.
• Recommend improvements to Work Instructions, Job Aids, and Policy and Procedures.

Minimum Qualifications

• Active, unrestricted pharmacist license.
• 2+ years of state regulatory and audit utilization management experience at a PBM or health plan.
• Extensive knowledge of operationalizing regulatory requirements.
• Strong oral and written communication skills.
• Intermediate to advanced Microsoft Excel skills.
• Strong analytical skills, attention to detail, and problem-solving abilities.
• Ability to work independently and collaboratively in a remote, high-volume, metric driven environment.

Preferred Qualifications

• Experience with URAC and NCQA accreditation requirements.
• Utilization management and/or appeals audit experience.
• 3+ years of compliance or regulatory experience at a PBM or health plan.

Additional Information

This flexible position may see duties reassigned as needed to meet organizational goals. All employees must adhere to the Capital Rx Code of Conduct.

Key skills/competency

• Regulatory
• Audit
• Compliance
• Quality Assurance
• Utilization Management
• Pharmacy
• Reporting
• Excel
• Analytical
• Communication