Quality Assurance (QA) Pharmacist - Medicare
Posted on October 29, 2025 (about 4 hours ago)
About Us:
Judi Health is a health technology company offering a wide range of benefits administration solutions for employers and health plans. This includes Capital Rx, a public benefit corporation that provides full-service pharmacy benefit management (PBM) solutions to self-insured employers; Judi Health™, which offers comprehensive health benefit management solutions for employers, TPAs, and health plans; and Judi®, the industry’s leading proprietary Enterprise Health Platform. To learn more, visit www.judi.health.
Position Summary:
The Medicare QA Pharmacist will perform routine auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance of Medicare coverage requests and appeals. The Medicare QA Pharmacist will utilize a strong comprehension of Centers for Medicare & Medicaid Services (CMS) guidance and regulatory requirements to ensure success in annual reporting (CDR, ODR), program audits (CDAG & ODAG), and ad hoc audits.
Position Responsibilities:
- Complete monthly coverage determination, organization determination, and appeals performance and process audits in alignment with CMS regulations and best practices.
- Create and maintain progress reports and audit results in accordance with regulatory requirements and internal processes.
- Present audit results to leadership in a timely manner to address issues and ensure adherence to departmental procedures and regulatory requirements (CMS, URAC, NCQA).
- Continuously review and remain informed of all CMS regulatory requirements and updates impacting the coverage request and appeals processes.
- Respond to inquiries from internal and external stakeholders regarding quality assurance processes, audit results, and compliance policies and procedures.
- Work independently and with team members as warranted by audit assignment.
- Assist in designing and implementing audit tools and programs, creating QA scorecards and guides in collaboration with all department stakeholders.
- Provide ongoing performance feedback, to team leads to ensure consistent performance.
- Assist management in identifying, evaluating, and mitigating operational, and compliance risks.
- Work in collaboration with operational leaders to identify training opportunities and recommend improvements to Work Instructions, Job Aids, and Policy and Procedures to improve performance.
Minimum Qualifications:
- Active, unrestricted, pharmacist license required
- 2+ years Medicare coverage determination, organization determination, and/or appeals audit experience required
- Extensive knowledge of how to operationalize Medicare requirements
- Strong oral and written communication skills required
- Intermediate to advanced Microsoft Excel skills required
- Possess strong analytical skills, attention to detail, quantitative, and problem-solving abilities
- Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven work environment
- Ability to multi-task and collaborate in a team with shifting priorities
Preferred Qualifications:
- CMS program audit experience
- Familiarity/experience with URAC and NCQA regulatory requirements
- 1+ years of compliance or regulatory experience at a PBM or health plan
Salary Information:
Salary Range $135,000 - $145,000 USD
Apply for this job through the job board link provided on the page. Fill out the online application form including personal information, resume/CV attachment, and other required data as indicated.