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.

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.

Claims Quality Assurance Specialist

Key skills