Quality Analysist Participant Services

Essential Functions

• Perform routine quality audits using approved scorecards.
• Evaluate documentation accuracy and policy adherence.
• Prepare weekly and monthly quality reports.
• Provide objective audit feedback to leaders.
• Identify root causes and recurring defect trends.
• Support coaching effectiveness through post-audit validation.
• Monitor daily operational performance against SLA, productivity, quality, and schedule adherence goals.
• Ensure compliance with HIPAA, CMS, state board of pharmacy requirements, and internal policies.
• Use reporting to identify trends and recommend corrective actions.
• Partner with Workforce Management, Training, Operations, and Leadership.
• Support continuous improvement initiatives and standardization efforts.
• Maintain documentation and confidentiality standards.
• Participate in calibration sessions and business meetings.
• Lead or support special projects as assigned.
• Support non-clinical prescription processing and participant service workflows.

Knowledge, Skills, And Abilities

• Strong written and verbal communication.
• Leadership and relationship-building skills.
• Critical thinking and analytical ability.
• Ability to prioritize competing demands.
• Experience working across multiple pharmacy systems.
• Proficiency with Microsoft Office, particularly Excel.
• Ability to maintain confidentiality.

Minimum Qualifications

• A High School Diploma or GED.
• Three or more years of relevant PBM, specialty pharmacy, participant services, or healthcare operations experience.
• Previous leadership or quality experience appropriate to the role.

Preferred Qualifications

• Active Arizona or Texas Pharmacy Technician License.
• National Pharmacy Technician Certification (CPhT).
• PBM or specialty pharmacy experience.
• Call center healthcare operations experience.
• Lever/Six Sigma or process improvement exposure.
• Experience presenting operational metrics.

Work Environment & Physical Requirements

• Fast-paced, computer-based participant services environment requiring prolonged sitting, frequent computer use, telephone communication, and the ability to manage multiple priorities while maintaining accuracy and professionalism.