Quality Oversight Analyst

What you’ll do

In a few words…

Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning.

The Pharmacy Benefit Manager Operations & Services team manages services from Medication Therapy Management (MTM), price eligibility, configurations, and beneficiary services to government services and beyond. Within this division, our Quality Assurance & Oversight team leads our quality oversight, root cause analysis, findings and corrective actions regarding adjudications and pharmacy claims.

As a Quality Oversight Analysts, you will be at the forefront of claims defect management and adjudication verification by collaborating within the Quality Oversight Department to maximize quality controls, diminish defects and ensure effective deployment of functionalities. You will execute thorough pharmacy claims testing and monitoring activities that cover areas such as new client implementations, current client changes, updates to functional requirements, among many others. Monitoring key performance indicators (KPI) will also be in your wheelhouse as you collaborate with areas like Coverage Determinations. We’ll trust you to make recommendations for corrective actions, mitigation and process improvements based on your findings as well as executing different quality improvement projects as needed.

The fundamentals for the job…

• Review paid and rejected claims to assure appropriateness in the adjudication processes according to client’s formulary, Drug Utilization Review (DUR) settings, benefit design, and laws and regulations.
• Assure beneficiary access to medications when an inappropriate rejection is detected.
• Collaborate with the Prescription Drug Event (PDE), Quality Action Notice (QAN), Audit and Regulatory Committee Management (RCM) processes when requested.
• Generate and monitor key performance indicators (KPI’s) of assigned tasks and other areas.
• Read release documentation for our proprietary platform and adjudication system, and be aware of any change or new functionality that could impact compliance with Centers for Medicare & Medicaid Services (CMS), and state regulations and/or benefit design.
• Collaborate in the development of new logics and procedures to improve processes in your areas of responsibilities.
• Write and update policies and procedures in your areas of responsibilities.
• Identify gaps in the adjudication system and propose improvements to avoid future gaps.
• Participate in system testing to ensure that new benefits, functionalities, or improvements are accurately working, and if applicable, any identified gap is fixed.
• Contact network pharmacies to verify claim information.
• Review prescriptions and other auditable documents to verify compliance with Centers for Medicare & Medicaid Services (CMS) requirements and contractual requirements.
• Complete data entry into applicable systems and logs to ensure all documentation related to claims review and quality monitoring procedures are maintained for audit purposes.
• Achieve the performance goals/targets and timeframe targets established for the position.

What we expect of you

The bold requirements…

• Bachelor’s Degree or Master’s Degree in Business, Engineering, Healthcare, or related field. (In lieu of a degree, equivalent relevant experience may be considered.)
• 3+ years of relevant experience in a non-retail pharmacy setting.
• Experience within the Healthcare, in Pharmacy Benefit Management (PBM), and/or Insurance industries.
• Experience in analyzing data sets using dashboards and database tools (e.g. Tableau, SQL and Excel tools).
• Excellent oral and written communication skills.
• We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only)

Nice to haves…

• Experience in Pharmacy Benefit Management (PBM) within Quality Assurance or Configuration role.
• Experience with PBM operations, pharmacy claims paid and reject review, pharmacy benefit configuration or testing, Centers for Medicare & Medicaid Services (CMS) policies, Fraud Waste & Abuse (FWA) policies and procedures, and Medicare Part D.

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Applicant must be a United States’ citizen. Abarca Health LLC does not sponsor employment visas at this time”

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.