Cigna Part D Quality Review/Audit Specialist-Phoenix, AZ! in Phoenix, Arizona


The Quality Review Audit Specialist Team Leader is responsible for providing oversight of our PBM’s performance. This position will provide quality assurance, lead projects, and provide oversight support of complex business processes both internal and external to the organization in support of Cigna-HealthSpring Pharmacy Operations’ initiatives defined in the organizational strategic plan.

The Quality Review Audit Specialist Team Leader position will interact and work with Pharmacy Operations management, Pharmacy Services team, and our external PBM on a regular basis. This position works closely with Pharmacy Operations management to conduct audits and analyze results to further improve the quality of services provided to the Cigna-HealthSpring members, pharmacies, and providers.

The Quality Review Audit Specialist will also conduct validations, monitor and analyze data to ensure requirements are met, perform research and analytical work of the internal staff, particularly in the areas of performance benchmarking, action plan tracking, and reporting. This position will be responsible for developing, designing and implementing, and training, for future audits and controls.

Team must identify pharmacy billing, benefit, and coding errors and track these errors to resolution. For claims with Prior Auths, this team must complete all reviews and corrections to claim records must be made in the system and/or conduct a Pharmacy call reach out within 24 hours of claim rejection. Weekend coverage is expected of this team and for the position of Team Leader.


•HR management responsibilities will include but not limited to: Time tracking and approvals, employee performance monitoring, coaching and development of direct reports, oversight and enforcement of Corporate employee protocols.

•Candidate will provide ongoing training, oversight and guidance to the team.

•Candidate may also be required to assess impact and determine implications of rejects from a cost, efficiency, contractual, legal and/or regulatory standpoint.

•Evaluates operational inventory status, calibrates staffing work assignments and schedules, establishes priorities and monitors progress of the inventory and team members.

•Compiles and analyzes results of services for identification of improvement opportunities.

•Produces, and improves line of business scorecards.

•Defines and consults on measurement strategies, tools, scorecards and surveys.

•Assists with providing measurement and cost savings support (development, reporting, validation and improvement) for service management.

•May coordinate with other internal Operational managers within Organization and other functional areas.

•May assist Operations Managers with other projects or initiatives as needed

•Researches and reviews complex cases, to identify core needs and to resolve issues.

•Responsible for performing validation audits and or monitoring PBM's performance on specific measures. This will include working directly with the PBM at multiple levels to ensure business needs are met.

•Develop new audits and controls for focus areas identified by management. This will include designing, implementing, training, and performing the function.

•Responsible for the development and analysis of quality and productivity measurements to Simplify and/or improve processes, determining performance standards by tracking and trending data. Working with functional owners to create, and implement initiatives as a result of this tracking and trending.

•Serve as the Subject Matter Experts relating to departmental goals, standards, policies and procedures and SOP's and the alignment with other departments within the organization.

•Serve as a Subject Matter Expert on system related initiatives, create business requirements documents for system implementations and play a key role in implementation and user acceptance testing. Negotiates change through matrix partners, serves as a technical, procedural and workflow resource for improvement teams, matrix partners and management

•Reports on an on-going basis the effectiveness of various Pharmacy Services and Pharmacy Operations activities and departmental procedures, including identifying and validating opportunities/recommendations.

•Uses various software applications, such as spreadsheets, relational databases, statistical packages, and graphics packages to assemble, manipulate and/or format data and/or reports.

•Provides support to the Pharmacy department by creating, validating, analyzing and maintaining various Pharmacy Operations related reports.

•Responsible for gathering, compiling, analyzing, maintaining and reporting of Quality Assurance data; tracking and trending for the Pharmacy Department.

•Provides feedback to individuals or groups regarding performance and appropriate departmental processes and guidelines. This will include developing various types of documentation from talking points to training documents.

•Develop and perform presentations based on functions above to be presented within and outside of the Pharmacy Department.

•Review and Update system documentation, based on current process.


Requirements and Qualifications:

•HSD or GED required; BA preferred

•3 years of experience in data analysis and management, operations analysis, or quality review

•2 years of work experience in Medicare Pharmacy claims systems required

•CPhT OR PBM Pharmacy Tech Certification PREFERRED

•Intermediate working knowledge of Microsoft Office including Outlook, Power Point, Excel and Word; SQL a PLUS

•Possesses a thorough knowledge of the interdependencies among Medicare business teams and matrix partners.

•Proven analytical experience, communication and organization skills

•Previous working experience in service, call center or case management environments.

•Proven ability to be proactive and effective in a fast paced environment, manage time and stay organized.

•Excellent conceptual and analytical skills, ability to: identify lineage between interfacing systems and processes, identify issues and to manage/execute solutions to resolution.

•Experience with quality assurance or auditing methodology and processes are a plus

Primary Location: Phoenix-Arizona

Work Locations: 25500 N Norterra Drive, Bldg B Phoenix 85085

Job: Bus Ops--Quality Assur/Audit

Schedule: Regular

Shift: Standard

Employee Status: Manager of People

Job Type: Full-time

Job Level: Day Job

Travel: Yes, 25 % of the Time

Job Posting: Mar 14, 2018, 8:51:38 AM

Cigna is an equal opportunity employer, which means we offer equal treatment to all applicants. Cigna does not discriminate, either directly or indirectly, on the grounds of race, color, sex, gender identity, sexual orientation, nationality, national origin, ethnic origin, religion, beliefs or creed, age, disability, marital status, veteran status or genetic information in any area of recruitment. In some countries we ask for information on the ethnic origin, gender and disability of our applicants for the purpose of monitoring equal opportunity. If you have a disability and would like to indicate as part of your application any relevant effects of your disability and any adjustment which you consider should reasonably be made to the process to assist your application, please do so in the relevant field during the application process.