Pharmacy Quality Assurance Analyst

Zing Health, Inc.; Alton (IL); Presencial; USD 90.000 - 130.000; Jornada completa

Descripción de la vacante

Zing Health, Inc. is seeking a detail-oriented Pharmacy Quality Assurance Analyst to ensure Pharmacy Operations align with CMS and NCQA standards. You will drive compliance, audits, and process improvements while supporting internal and external reviews.

The role includes developing CMS/NCQA training, analyzing claims data for quality controls, and coordinating reconciliations and audits across pharmacy units. Bilingual English/Spanish is preferred; evenings or weekends may be required.

Formación

• Detail-oriented QA Analyst with CMS/NCQA knowledge.
• Experience auditing and ensuring compliance with regulatory standards.
• Ability to develop training on CMS/NCQA requirements.

Responsabilidades

• Evaluate current policies and procedures against CMS/NCQA requirements.
• Develop and deliver training on CMS/NCQA requirements; monitor operations and recommend corrective actions.
• Lead recovery efforts for COB, ESRD, Hospice, PDEs, LICs, P2P and related processes.
• Analyze claims and utilization data to ensure quality controls.
• Reconcile vendor invoices and resolve member/provider issues from Salesforce cases.
• Oversee FIR and COB backend reconciliation activities.
• Manage monthly quality checks for marketing materials (print and web).
• Perform monthly audits and exams across pharmacy units.
• Support CMS Financial, Operational, and NCQA audits.
• Maintain audit samples and monitor performance metrics.
• Manage annual updates to policies, procedures, and training logs.
• Lead execution of the Pharmacy Internal Audit Plan.

Conocimientos

Attention to detail

CMS/NCQA knowledge

Training & instruction

Data analysis

Vendor management

Audit management

Project management

Technical writing

BI analysis

SQL data queries

Bilingual (English/Spanish)

Object-oriented analysis

Educación

Bachelor's degree

Herramientas

SQL

Salesforce

Descripción del empleo

Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65-and-over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the healthcare equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs, and a dedicated care team. For more information on Zing Health, visit

A detail-oriented and experienced Pharmacy Quality Assurance Analyst to ensure Pharmacy Operations align with regulatory standards set by CMS and NCQA. This role is critical in maintaining compliance, driving process improvements, and supporting internal and external audits.

Evaluate current policies and procedures against CMS/NCQA requirements; Ensure system enhancements and implementations meet business and regulatory needs.

Develop and deliver training on new CMS/NCQA requirements; monitor pharmacy operations and recommend corrective actions.

Lead recovery efforts for COB, ESRD, Hospice, PDEs, LICs, P2P, and related processes.

Analyze claims and utilization data to ensure quality controls are in place.

Reconcile vendor invoices and resolve member/provider issues from Salesforce cases.

Oversee FIR and COB backend reconciliation activities.

Manage monthly quality checks for marketing materials (print and web).

Perform monthly audits and exams across pharmacy units.

Support CMS Financial, Operational, and NCQA audits.

Maintain audit samples and monitor performance metrics.

Manage annual updates to policies, procedures, and training logs.

Lead execution of the Pharmacy Internal Audit Plan (e.g., FIR/Nx Rejects, PDE Monitoring, MTM, Formulary Administration, Claims Processing).

Registered Pharmacy Technician & Certification

Bachelor’s degree or 5+ years of healthcare experience.

Experience with SQL data queries and report generation is a plus.

Bilingual (English/Spanish) preferred.

Business intelligence and comparative analysis.

Project management and technical writing.

Proficiency in business modeling and object-oriented analysis.

Comfortable working flexible schedules (nights, weekends, holidays).