Quality Assurance (QA) Pharmacist - Medicare
Posted on October 29, 2025 (about 4 hours ago)
About Us:
Judi Health is a health technology company offering various benefits administration solutions for employers and health plans, including Capital Rx, Judi Health™, and Judi®, an Enterprise Health Platform.
Position Summary:
The QA Pharmacist performs routine auditing and monitoring to ensure quality, accuracy, and regulatory compliance of coverage requests and appeals, using knowledge of regulatory requirements for reporting and audits.
Position Responsibilities:
- Conduct monthly utilization management and appeals performance audits per regulations and standards.
- Create and maintain progress reports and audit results based on regulatory and internal requirements.
- Present audit results to leadership to ensure adherence to procedures and compliance requirements (CMS, URAC, NCQA).
- Stay informed on regulatory updates affecting coverage request and appeals processes.
- Respond to inquiries about quality assurance, audit results, and compliance policies.
- Work independently and collaboratively on audit assignments.
- Help design and implement audit tools, QA scorecards, and guides with department stakeholders.
- Provide performance feedback to team leads.
- Assist management in evaluating and mitigating operational and compliance risks.
- Collaborate with operational leaders to identify training needs and recommend improvements to documentation for better performance.
Minimum Qualifications:
- Active, unrestricted pharmacist license required.
- 2+ years of utilization management experience required.
- Extensive knowledge of operationalizing regulatory requirements.
- Strong oral and written communication skills.
- Intermediate to advanced Microsoft Excel skills.
- Strong analytical, detail-oriented, quantitative, and problem-solving abilities.
- Ability to work independently in a remote, metric-driven environment.
- Ability to multitask and collaborate in a shifting priority team setting.
Preferred Qualifications:
- Familiarity with URAC and NCQA accreditation requirements.
- Experience in utilization management and/or appeals audit.
- 1+ years of compliance or regulatory experience at a PBM or health plan.
This position description is flexible to allow reassignment of duties as needed to meet organizational goals.
Judi Health values diversity and provides equal employment opportunities without discrimination based on protected characteristics under applicable laws.
To apply for this job, please visit the original job posting page and submit your application through the provided form. The application process includes uploading your resume/CV, cover letter, and providing relevant personal and professional information as requested.