Manager, Quality Assurance (Pharmacy - PBM)

What you'll do

In a few words…

Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…

Providing high quality services to client and beneficiaries is at the core of what we do every day! The PBM Operations & Services team is the very heart of Abarca and meets that standard by running services from MTM, price eligibility, configurations, and beneficiary services to government services and beyond. Within this division, our Quality Assurance & Oversight team leads the charge in quality oversight, root cause analysis, findings and corrective actions regarding adjudications and pharmacy claims.

As a Manager, Quality Assurance you will lead the Quality Assurance team and would be responsible to develop and direct the timely performance and completion of all our quality assurance activities. You will also be responsible to lead recurring and impromptu quality assurance tests and monitoring activities as part of projects, new client implementations, current client change, and/or new functional requirements implementations, ensuring the quality of the systems and processes that support the company’s operation. You will identify and provide feedback on potential operational issues, analyzing and identifying solutions to resolve claims processing issues and other operational gaps and mishaps. We count on you to help point out process improvement opportunities to make the configuration of benefit plan designs more efficient.

The fundamentals for the job…

• Monitor overall performance and manage the development, coordination, and administration of the Quality Assurance team, including setting, reviewing and measuring quality standards, documentation standards, processes and procedures, performance reviews, quarterly/semiannual check-ins and staff meetings to guide performance management and employee development efforts and direct them toward departmental goals, including quality and process improvement efforts.
• Develop, track and report key quality metrics to monitor and report on testing and quality efforts and results to business stakeholders and company leads.
• Develop, supervise, and perform quality assurance of benefit set-up, network, pricing, and formulary configurations.
• Lead the preparation and implementation of quality assurance activities such as testing, policies, procedures, workflows, and training.
• Contribute to the business requirement gathering process by identifying missing requirements based on test cases development and testing experience.
• Assist in gathering proper and accurate documentation and data during internal and external audits related to the Company’s PBM processes.
• Stay up to date on external regulator guidelines (such as Medicare, Medicaid, and state requirements) to assess that adjustments made to operational processes are in compliance with rules and regulations.

What we expect of you

The bold requirements…

• Bachelor’s Degree or Master’s Degree in Business, Engineering, Healthcare, or related field. (In lieu of a degree, equivalent, relevant work experience may be considered.)
• 8+ years of experience in benefits configuration and testing within a non-retail pharmacy setting.
• 3+ years of experience managing a team.
• Experience with PBM Operations, Member Services, Pharmacy Networks; Fulfillment, Call Center, and Medicare.
• Experience with dashboard tools (e.g., Tableau, Structured Query Language and Excel tools)
• Must be willing to travel (10% of time) per year (in state or out of state).
• Excellent oral and written communication skills required.
• We are proud to offer a flexible hybrid work model which will require certain on-site workdays

Nice to haves…

• Bilingual fluency in Spanish and English.
• Training and experience in testing methodologies.
• Programming knowledge.

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Applicant must be a United States’ citizen. Abarca Health LLC does not sponsor employment visas at this time”

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.

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