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Job Title:

SHP Pharmacy Quality Assurance - Auditing Specialist (Remote, hybrid or in office)

Cost Center:

682891381 SHP-Pharmacy

Scheduled Weekly Hours:

40

Employee Type:

Regular

Work Shift:

Mon-Fri; 8:00 am - 5:00 pm (United States of America)

Job Description:

JOB SUMMARY

The SHP Pharmacy Quality Assurance/Auditing Specialist monitors, performs, and manages quality assurance processes including those supporting compliance to regulatory and accreditation standards. This role works closely with the Security Health Plan (SHP) compliance team in monitoring regulatory guidelines and investigating instances of fraud, waste, and abuse as it pertains to SHP pharmacy issues and with the SHP quality improvement team in activities and requirements pertaining to National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), and 5 Star Quality Measures.

Position can be remote or in office.

JOB QUALIFICATIONS

EDUCATION

For positions requiring education beyond a high school diploma or equivalent, educational qualifications must be from an institution whose accreditation is recognized by the Council for Higher Education and Accreditation.

Minimum Required: High school diploma or equivalent. Post-secondary courses in medical terminology, pharmacology and health insurance or managed care.

Preferred/Optional: None

EXPERIENCE

Minimum Required: Five years’ experience as a pharmacy technician in a retail pharmacy and an HMO pharmacy environment. Expertise in electronic pharmacy claims processing and pharmacy claims processing systems.

Preferred/Optional: Experience in quality assurance and auditing functions and experience with National Committee for Quality Assurance (NCQA) or Healthcare Effectiveness Data and Information Set (HEDIS) standards.

CERTIFICATIONS/LICENSES

The following licensure(s), certification(s), registration(s), etc., are required for this position. Licenses with restrictions are subject to review to determine if restrictions are substantially related to the position.

Minimum Required: Certified Pharmacy Technician (CPhT) provided by the Wisconsin Department of Safety and Professional Services (DSPS).

Preferred/Optional: None

1. Designs and implements internal and external pharmacy auditing plans for commercial and Medicare lines of business to ensure regulatory requirements are met and to verify the accuracy of operational processes.

2. Designs and implements processes to support accreditation activities pertaining to pharmacy in order to maintain qualified accreditation status.

3. Provides regular formal updates to staff on current applicable accreditation standards, state and federal quality improvement requirements in order to incorporate the most current standards and requirements into staff daily workflow.

4. Collaborates with interdepartmental workgroup teams for quality improvement initiatives to improve Healthcare Effectiveness Data and Information Set (HEDIS) standards and five star ratings.

5. Assists leadership with developing and implementing metrics and performance targets to assess compliance with Center for Medicare and Medicaid Services (CMS) regulations.

6. Adapts existing plans and processes to accommodate new federal/state requirements for government sponsored drug programs and utilization of new technologies to maintain compliance.

7. Reviews and updates Pharmacy policy and procedure documents to ensure the department is in compliance with the Center for Medicare and Medicaid Services (CMS), Office of the Commissioner of Insurance (OCI), National Committee for Quality Assurance (NCQA), and any other applicable regulatory guidelines.

8. Maintains working knowledge of the various pharmacy documenting systems utilized within the department and monitors accuracy of staff utilization of those documenting systems to ensure operational and security parameters are followed consistently.

9. Regular attendance is required in order to carry out the essential functions of the position.

10. Reviews and meets ongoing competency requirements of the role to maintain the skills, knowledge and abilities to perform, within scope, role specific functions.

Marshfield Clinic Health System is committed to enriching the lives of others through accessible, affordable and compassionate healthcare. Successful applicants will listen, serve and put the needs of patients and customers first.

At Marshfield Clinic Health System, we are fully committed to addressing health equity, diversity and inclusion for our employees and providers, our patients, and the communities we serve. We believe that every individual should have the opportunity to attain their highest level of health. We embrace diversity and welcome differences in who we are and how we think. We believe that any individual or group should feel welcomed, respected and valued. View our Equity and Inclusion Statement here (https://www.marshfieldclinic.org/mAboutUs/Documents/30922-000_Equity-and-Inclusion-Statement%20%282%29.pdf) .

Exclusion From Federal Programs: Employee may not at any time have been or be excluded from participation in any federally funded program, including Medicare and Medicaid. This is a condition of employment. Employee must immediately notify his/her manager or the Health System’s Compliance Officer if he/she is threatened with exclusion or becomes excluded from any federally funded program .

Marshfield Clinic Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.

We’re hiring! Use “remote” or “hybrid” as a keyword in the search to see our remote-eligible openings!

When given the tools needed to excel, great things happen: connection with colleagues, recognition in the community, better care for our patients. All this is available with affordable living rich in leisure. Welcome to Marshfield Clinic Health System . Where career meets community.

Positions listed as 30 hours per week or greater are offered the level 1 benefit package.

Positions listed as 20 – 29 hours per week are offered the level 2 benefit package.

Positions listed as less than 19 hours per week are non-benefited.

Benefits for temporary positions vary. Details will be discussed in the interview process.

At Marshfield Clinic Health System, we are fully committed to addressing health equity, diversity and inclusion for our employees and providers, our patients, and the communities we serve.

We believe that every individual should have the opportunity to attain their highest level of health. We embrace diversity and welcome differences in who we are and how we think. We believe that any individual or group should feel welcomed, respected and valued. View our Equity and Inclusion Statement here (https://www.marshfieldclinic.org/mAboutUs/Documents/30922-000_Equity-and-Inclusion-Statement%20%282%29.pdf)