Quality Control Specialist - Medicare Pharmacy Claims

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

This role is responsible for reviewing Medicare pharmacy claims to ensure compliance with CMS requirements and prevent access-to-care issues. The Quality Control Specialist conducts regular audits to verify adherence to regulations, internal policies, and operational procedures, while maintaining thorough documentation to support potential CMS program audits. This role also identifies error trends and root causes, recommends process improvements, and contributes to updating job aids and procedures. As a key team member, the specialist is expected to drive improvements that enhance the accuracy, efficiency, and overall quality of Pharmacy Operations.

JOB REQUIREMENTS:

• High school diploma or GED.
• 2 years business experience. A combination of college level education and experience will be considered
• Clear and concise interpersonal, verbal and written communication skills to facilitate the learning process; coaching and mentoring skills
• PC experience in Windows, Word, Excel, Access, and other business related/associated databases.
• Demonstrated analytical and organizational skills

PREFERRED JOB REQUIREMENTS:

• Advanced Excel skills including vlook-ups, pivot tables
• Practical experience of 1+ years providing oversight of Medicare pharmacy claims
• 1-2 years pharmacy claims experience and/or managed care experience preferred.
• Knowledge of CMS Guidance of MAPD, Part D Plans, and EGWP
• Experience with Audits preferred
• Critical Thinker- able to analyze, interpret, explain, self-regulate, open-minded and problem solving mind set
• Capable of explaining complex issues in a concise manner
• CPhT preferred, but not required
• SQL (Teradata) Knowledge preferred

This is a Remote role.

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Compensation: $20.04 - $44.61

Exact compensation may vary based on skills, experience, and location

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

To learn more about available benefits, please visit https://careers.hcsc.com/totalrewards (opens in new window)