Pharmacy Quality Assurance Analyst

Zing Health Holdings Inc; Illinois; On-site; USD 70,000 - 110,000; Full time

Job summary

Zing Health Holdings Inc. is seeking a detail-oriented Pharmacy Quality Assurance Analyst to ensure Pharmacy Operations align with CMS and NCQA standards. You will evaluate policies, develop training, monitor HIPAA-related processes, and lead audits across COB, ESRD, PDEs, LICs, and MTM.

Strong SQL/reporting skills and bilingual English/Spanish are preferred. Join a team dedicated to regulatory compliance, continuous process improvement, and accurate auditing of vendor invoices, marketing

Qualifications

• Evaluate CMS/NCQA requirements and ensure system enhancements meet business and regulatory needs.
• Develop and deliver training on 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).
• Experience with SQL data queries and report generation is a plus.

Responsibilities

• Evaluate current policies and procedures against CMS/NCQA requirements.
• 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.

Skills

SQL queries

Report generation

BI analysis

Project management

Technical writing

Object-oriented analysis

Bilingual EN/ES

Education

Bachelor’s degree

Pharmacy Technician Certification

Tools

Salesforce

Job description

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).