Job Summary & Responsibilities

The Quality Oversight Specialist is primarily responsible for the oversight of adjudicated claims (paid and rejected) to validate the accuracy of benefit and formulary set-ups, as well as compliance with laws and regulations. In addition, the Quality Oversight Specialist may perform quality and monitoring of key performance indicators (KPI) of operational programs such as Coverage Determination. This position shall make recommendations for corrective action and process improvement based upon claims oversight and program monitoring findings.

This position will also be responsible for executing quality improvement projects based on findings identified. These responsibilities will be assigned on a special assignment basis.

Responsibilities include but are not limited to:

  • Review of paid and rejected claims to assure appropriateness in the adjudication processes according to client’s formulary, DUR settings, benefit design, and laws and regulations.
  • Assure beneficiary access to medications when an inappropriate rejection is detected.
  • Collaborate with the PDE, QAN, Audit and RCM Committees/procedures when requested.
  • Generate and monitor KPIs of assigned tasks and other areas as assigned.
  • Read RxEngine and RxPlatform releases documentation and be aware of any change or new functionality that could impact compliance with CMS and state regulations and/or benefit design.
  • Collaborate in the development of new logics and procedures to improve processes on their areas of responsibilities.
  • Responsible for writing and updating policies and procedures of their areas of responsibilities.
  • Identify gaps in the adjudication system and propose improvements to avoid future gaps;
  • Participate of system testing to ensure that new benefit, functionalities or improvements are accurately working, and if applicable, any identified gap is fixed.
  • Contact network pharmacies to verify claim information;
  • Review of prescriptions and other auditable documents to verify compliance with CMS requirements and contractual requirements;
  • Conduct reviews and investigations of claims referrals to ensure PDE accuracy.
  • Conduct reviews and investigations of APAP Client claims referrals to ensure correct dosing, quantity dispensed and day supply values submitted by the Pharmacies;
  • Confirm the reversing and/or reprocessing of claims identified during PDE or APAP reviews, which have been previously processed with errors, to correct them to prevent future PDE rejections.
  • Complete data entry into applicable systems and logs to ensure all documentation related to claims review and quality monitoring procedures are maintained for audit purposes;
  • Achieve the performance goals/targets and timeframe targets established for the position;
  • Maintain positive relationships with network pharmacies in performing day to day job responsibilities;
  • Perform other duties and special projects as assigned.

Required professional experience & Professional Competencies

  • Minimum 2 years of experience in a non-retail pharmacy setting or as a Pharmacy Auditor (preferred);
  • Knowledge of the Healthcare, Pharmacy Benefit Management, and/or Insurance industries;
  • Experience/knowledge with PBM operations, CMS FWA policies and procedures and Medicare Part D is a plus;
  • Demonstrated initiative with commitment and ability to work under pressure and meet tight deadlines;
  • Must be proficient with Microsoft Excel, knowledge of Microsoft Office products, and Internet experience;
  • Clinical knowledge, good analytical and attention to detail skills;
  • Must be able to communicate effectively (read, speak, and write) in English and Spanish.

required education, training & Licensure/certifications

  • Certified Pharmacy Technician or Associates Degree or Bachelor’s Degree;
  • Bachelor’s Degree in Biology, or related discipline is a plus;
  • Certificate of No Penal record.
  • HIPAA, both Security & Privacy; Confidentiality, & Fraud, Waste and Abuse (FWA)*
  • Must be able to lift a minimum 10 pounds.

Physical Requirements

· Must be able to remain in a stationary position for a large part of the work day.

· The person in this position needs to occasionally move about inside the office to access other employees, file cabinets, office machinery, etc.

· An employee must be able to talk, hear, and see, and must be able to grasp objects.

· Visual acuity is necessary in order to read and write handwritten and typewritten materials and view a computer terminal.

· Constantly operates a computer and other office productivity machinery (i.e., a calculator, copy machine, and computer printer). Use of hands (specifically fingers) is necessary for appropriate and efficient computer use.

EEO Statement

abarca health is an Equal Employment Opportunity employer and does not discriminate in employment opportunities or practices on the basis of race, creed, color, religion, sex, national origin, nationality, ancestry, age, disability or status as a disabled veteran or veteran of the Vietnam era, pregnancy, affectional or sexual orientation, gender identity or expression, marital status, status with regard to public assistance, veteran status, citizenship or membership in any other legally protected class. None of the questions in the job application or interview are intended to elicit information regarding any protected characteristics, nor imply any limitation, illegal preferences or discrimination based upon non-job-related information or protected characteristics. Applicants must be able to pass a drug test, background investigation and, depending on position requirements, an analytical exam and/or a Department of Defense background investigation.


This specification is intended to indicate the kinds of tasks and levels of work difficulty that will be required of positions that will be given this title and shall not be construed as declaring what the specific duties and responsibilities of any particular position shall be. It is not intended to limit or in any way modify the right of any supervisor to assign, direct, and control the work of employees under his/her supervision. The use of a particular expression or illustration describing duties shall not be held to exclude other duties not mentioned. Ability to competently perform all the essential functions of the position, with or without reasonable accommodation, demonstrated commitment to effective customer service delivery, and the ability to work productively as a member of a team or work group are basic requirements of all positions at abarca health, LLC.

* to be completed within the first 90 days of employment at abarca health