Quality Control Specialist - Medicare Pharmacy Claims

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary This role is responsible for reviewing Medicare pharmacy claims to ensure compliance with CMS requirements and prevent access-to-care issues. The Quality Control Specialist conducts regular audits to verify adherence to regulations, internal policies, and operational procedures, while maintaining thorough documentation to support potential CMS program audits. This role also identifies error trends and root causes, recommends process improvements, and contributes to updating job aids and procedures. As a key team member, the specialist is expected to drive improvements that enhance the accuracy, efficiency, and overall quality of Pharmacy Operations. JOB REQUIREMENTS: High school diploma or GED. 2 years business experience. A combination of college level education and experience will be considered Clear and concise interpersonal, verbal and written communication skills to facilitate the learning process; coaching and mentoring skills PC experience in Windows, Word, Excel, Access, and other business related/associated databases. Demonstrated analytical and organizational skills PREFERRED JOB REQUIREMENTS: Advanced Excel skills including vlook-ups, pivot tables Practical experience of 1+ years providing oversight of Medicare pharmacy claims 1-2 years pharmacy claims experience and/or managed care experience preferred. Knowledge of CMS Guidance of MAPD, Part D Plans, and EGWP Experience with Audits preferred Critical Thinker- able to analyze, interpret, explain, self-regulate, open-minded and problem solving mind set Capable of explaining complex issues in a concise manner CPhT preferred, but not required SQL (Teradata) Knowledge preferred This is a Remote role. #LI-PD1 #LI-Remote INJLF Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! Pay Transparency Statement: At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards. The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan. HCSC Employment Statement: We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Base Pay Range $20.04 - $44.61 Exact compensation may vary based on skills, experience, and location. Apply To This Job