Quality Review and Audit Senior Analyst

  • Location

    Bloomfield, United States

  • Sector:

    Other Area(s)

  • Job type:


  • Contact:

    Leric Arcigal

  • Job ref:


  • Published:

    about 1 year ago

  • Expiry date:


Responsible for performing Medicare Pharmacy claim testing and validation audits in support of PBM systemreadiness. Monitoring specific measures such as reviewing claim adjudication accuracy related to benefit, formulary, co-pay and other system editing functions.

Responsible for monitoring pharmacy claims to identify errors with plan setup or prior authorizations

Responsible for validating transition claims are adjudicating in line with CMS guidance. Assist with writing Testing scenarios and macro build creation for readiness testing Support for multiple scenarios during testing and go-live review Ensure Medicare Pharmacy Claim Benefits are set up and working appropriately Ensure Pharmacy claim issues are identified and are submitted and corrected

Delivers specific delegated tasks assigned by a supervisor in the Quality Assurance/Audit job family. Completes day-to-day Quality Review and Audit tasks without immediate supervision, but has ready access to advice from more experienced team members. May assist in more complex audits where experience and wider business acumen is required. Contributes to the development of audit policies and procedures. Tasks involve a degree of forward planning and anticipation of needs/issues.