Claims Quality Auditor jobs in Madison, WI

Putting People First in Pharmacy- Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models.  We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them.   At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth.  We welcome new ideas and share a passion for excellent service to our customers and each other.  

Due to growth, we are adding Director, Claims Quality Assurance & Testing to our Customer Operations department.

We are unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.

The Director, Claims Quality Assurance & Testing is responsible for the overall testing strategy and execution spanning all new PBM client implementations and existing PBM client configuration changes. The role has direct ownership and accountability for testing and testing teams spanning all aspects of pharmacy benefit client deliverables.  This includes pre-adjudication inputs such as hierarchy, eligibility, plan benefits, formulary, utilization management, networks, historical claims and historical MPA data, as applicable.  In addition, it includes post-adjudication elements Such as claims extracts, EOBs, member portal views, API integrations and Prescription Drug Events.  Success in this role will require collaboration across the enterprise to ensure accurate and timely information and data flow to meet client requirements.

Is this you? Find out more below! 

How do I make an impact on my team?  

• Develops, implements, and manages a comprehensive quality testing strategy and center of expertise (CoE).
• Leads the CoE in performing quality testing for all new PBM client implementations and existing PBM client configuration changes.  This includes pre- and post-adjudication data elements.
• Serves as an organizational thought leader in defining and implementing the CoE tools, processes, and practices roadmap supporting optimal test automation frameworks considering the cost vs. benefit of automation where appropriate.
• Works with IT and any external vendor partners supporting the organizations’ technology environment to ensure reliable, cost effective, and optimized quality testing and customer support.
• Effectively communicates and collaborates with partners throughout the organization and external consultants, brokers and clients as needed to ensure alignment on testing methodologies, test data, defect tracking, and reporting of key quality testing metrics.  
• Maintains a solid working knowledge of new and trending technology, tools, processes, and other practices supporting quality testing for pharmacy benefits claims adjudication.
• As necessary, partners with the appropriate parties to ensure quality defects are communicated timely, and retests are conducted as needed.
• Provides input into key enterprise decision-making activities in support of the quality testing function, advising on best practices and providing alternative solutions to complex issues to ensure quality and effective governance.  Works independently with guidance in only the most complex situations.  
• Assumes responsibility for development, engagement, and retention of the quality testing team, completing all normal HR activities including staff recruiting, onboarding, development, performance management, and compensation management. 
• As assigned, performs other duties commensurate with the purpose, scope, skill, and knowledge requirements for the role.   

What our team expects from you? 

• Bachelor’s degree required.
• 10 years of quality assurance testing, with at least 3 year of experience performing similar work in the PBM or managed care industry is required.
• 5 years of people management experience is required.
• Prior involvement in pharmacy benefit claims system configuration, adjudication, and/or testing preferred.  
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Hours/Location: Monday-Friday 8:00am-5:00pm CST, Remote
• Paid Volunteer Hours
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!
• Top of the industry benefits for Health, Dental, and Vision insurance, Flexible Spending Account, Paid Time Off, Nine paid holidays, 401K, Short-term and Long-term disability, College Savings Plan, Paid Parental Leave, Adoption Assistance Program, and Employee Assistance Program

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