Claims Quality Assurance Specialist
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Job Description
Claims Quality Assurance Specialist ensuring accuracy and integrity in pharmacy benefit configurations at Navitus. Performing audits and testing activities to support quality assurance processes.
Responsibilities:
- Execute monthly quality assurance testing cycles, including client group selection, high utilization drug identification, test member preparation, adjudication file execution, results import, analysis, and month over month comparison.
- Validate adjudication results against plan grids, formularies, configuration documents, and other sources of truth; prepare QA deliverables and submit discrepancies for resolution.
- Design comprehensive test scenarios using live claim sampling, client issue history, and financially impactful drug categories to ensure adequate coverage.
- Develop and apply working knowledge of Navitus audit methodologies and end to end pharmacy benefit workflows to identify quality risks and downstream impacts.
- Identify, document, track, and retest defects as fixes are applied; support root cause analysis and resolution efforts.
- Perform peer reviews and quality checks to ensure adherence to audit criteria, validation standards, and business rules.
- Utilize QA and workflow tools (e.g., Qlik Sense, RxFlex, FBMS) to troubleshoot and resolve moderately complex adjudication and configuration issues.
- Maintain an intermediate understanding of adjudication systems, testing environments, and quality assurance methodologies.
- Participate in process improvement initiatives, documentation updates, training material development, automation efforts, and standardization activities.
- Other duties as assigned.
Requirements:
- Bachelor’s degree or equivalent work experience is required.
- Pharmacy Technician License or National Certification preferred.
- 5+ years of experience in quality assurance, benefit configuration, or data validation roles within a pharmacy benefit management (PBM) or similar payer environment required.
- Experience supporting clients in all lines of business of varying size and complexity preferred.
- Intermediate proficiency required in Microsoft Office (Excel, Word, PowerPoint), QlikView/Qlik Sense or comparable reporting tools, formulary management applications, request management platforms (ConnectUs, Service Desk, Jira, ServiceNow), and PBM adjudication or configuration systems (e.g., Navi ClaimRx).
- Prior experience with data analysis, defect tracking, or root cause analysis within a healthcare environment preferred.
- Participate in, adhere to, and support compliance program objectives.
- The ability to consistently interact cooperatively and respectfully with other employees.
Benefits:
- Top of the industry benefits for Health, Dental, and Vision insurance
- 20 days paid time off
- 4 weeks paid parental leave
- 9 paid holidays
- 401K company match of up to 5% - No vesting requirement
- Adoption Assistance Program
- Flexible Spending Account
- Educational Assistance Plan and Professional Membership assistance
- Referral Bonus Program – up to $750!
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