Quality Assurance (QA) Pharmacist - Medicare
Posted on September 29, 2025 (about 3 hours ago)
About Us:
Judi Health is a health technology company offering benefits administration solutions including Capital Rx, a public benefit corporation providing full-service pharmacy benefit management (PBM) solutions, Judi Health™ enterprise health platform, and Judi® benefits management solutions. For more details, visit www.judi.health.
Position Summary:
The Medicare QA Pharmacist will perform auditing and monitoring processes to ensure quality, accuracy, and regulatory compliance for Medicare coverage requests and appeals. They will utilize strong knowledge of CMS guidance and regulatory requirements to successfully support annual and ad hoc reporting and audits.
Position Responsibilities:
- Complete monthly audits of coverage determination, organization determination, and appeals performance in line with CMS regulations and best practices.
- Create and maintain progress reports and audit results per regulatory and internal requirements.
- Present audit findings to leadership promptly to address issues and ensure compliance with CMS, URAC, NCQA regulations.
- Stay updated on CMS regulatory requirements and changes affecting coverage and appeals processes.
- Respond to stakeholder inquiries about quality assurance, audit results, and compliance policies.
- Work independently or with team members on audit assignments.
- Assist in designing audit tools, QA scorecards, and guides in collaboration with departmental stakeholders.
- Provide ongoing performance feedback to team leads for consistency.
- Help management identify and mitigate operational and compliance risks.
- Collaborate with operational leaders to identify training needs and suggest improvements to procedures and instructions.
Minimum Qualifications:
- Active, unrestricted pharmacist license required
- 2+ years Medicare coverage determination, organization determination, or appeals audit experience
- Extensive knowledge of Medicare operational requirements
- Strong oral and written communication skills
- Intermediate to advanced Microsoft Excel skills
- Strong analytical skills, attention to detail, quantitative and problem-solving abilities
- Ability to work independently in a remote, high-volume, metric-driven environment
- Ability to multitask and collaborate in a team with shifting priorities
Preferred Qualifications:
- CMS program audit experience
- Familiarity with URAC and NCQA regulatory requirements
- 1+ years compliance or regulatory experience at a PBM or health plan
This position description is flexible to allow management to assign or reassign duties to meet organizational goals.
Capital Rx values diversity and provides equal employment opportunities, prohibiting discrimination based on protected characteristics.
You can apply for this job by filling out the application form available on the job posting page via the Greenhouse platform. It's necessary to provide your personal details including name, email, phone, and uploading your resume/CV. Additional questions related to experience, qualifications, legal work authorization, and voluntary self-identification are part of the application.
Application Instructions:
Use the provided form fields to submit your application. Ensure you complete all required fields marked with an asterisk (*). Attach your resume and cover letter if desired, following the accepted file types (pdf, doc, docx, txt, rtf).
Visit the application page through the link given in the job post to start your application process.