About The Position
The Quality Assurance Specialist is responsible for ensuring the accuracy, compliance, and integrity of claims processing, benefit configurations, and operational data. This role performs detailed audits and validation of pharmacy claims, system configurations, and plan setups to ensure they align with client requirements and benefit designs. The Quality Assurance Specialist collaborates closely with Operations, Implementation, and Technology teams to identify discrepancies, validate system functionality, and support continuous process improvement. Through testing, auditing, and data analysis, this role helps maintain high-quality standards across operational workflows and claims adjudication processes.
Requirements
- Experience in quality assurance, auditing, pharmacy benefit management, or healthcare operations.
- Familiarity with pharmacy claims processing and benefit design validation preferred.
- Strong analytical and problem-solving skills with experience conducting root cause analysis.
- Experience working with CRM systems, claims platforms, or operational data systems.
- Excellent organizational, documentation, and communication skills.
- Ability to collaborate effectively across departments and manage multiple priorities.
Responsibilities
- Test and validate pharmacy claims to ensure proper adjudication based on plan design and benefit configuration.
- Conduct pre- and post-implementation testing for new client setups, system updates, and benefit changes.
- Verify formulary configurations and tiering logic for accuracy and alignment with plan requirements.
- Review and validate plan setup and configuration within claims systems to ensure alignment with client requirements and benefit designs.
- Validate accumulator logic, including deductibles, out-of-pocket maximums, and benefit limits, to ensure accurate tracking and application during claims adjudication.
- Identify trends, anomalies, or discrepancies within claims data, member records, or benefit processing workflows.
- Investigate discrepancies or issues impacting claims adjudication, benefit calculations, or system data accuracy.
- Collaborate with cross-functional teams to identify root causes and implement corrective actions for identified issues.
- Solicit and incorporate feedback from operational and technical stakeholders to refine and improve quality assurance processes.
- Recommend and support process enhancements to improve operational quality, efficiency, and system reliability.
- Maintain detailed documentation of audits, testing results, quality reviews, and issue resolutions.
- Develop and update standard operating procedures (SOPs), work instructions, and quality standards.
- Prepare quality metrics, audit summaries, and trend analysis reports for internal stakeholders.
- Perform quality audits on CRM and operational data to ensure accuracy, consistency, and completeness.
- Validate system updates, configuration changes, and operational process changes to ensure expected outcomes are achieved.
- Perform other related duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
