Quality Review and Audit Senior Advisor - Express Scripts - Hybrid

Quality Review & Audit Senior Advisor

The Quality Review & Senior Audit Advisor provides enterprise-level quality assurance leadership with a strong focus on clinical accuracy, pharmacy benefit integrity, and regulatory compliance. This role applies advanced clinical and pharmacy expertise to validate benefit configurations, evaluate clinical program performance, and ensure alignment with CMS, NCQA, and state regulatory requirements across processes, systems, and training programs.

Serving as a clinical and pharmacy subject matter expert, the Senior Advisor partners with internal and external stakeholdersincluding Sales & Account Management, Technology, Configuration, Clinical Operations, Pharmacy, and Data Analyticsto resolve complex clinical and benefit-related issues that impact patient safety, access to care, regulatory compliance, and client outcomes. The role drives continuous improvement through clinically informed quality monitoring, root cause analysis, and data-driven insights, supporting the highest standards of quality, compliance, and operational excellence.

Responsibilities:

• Provide expert clinical and pharmacy oversight for quality monitoring and testing across Medicare, Medicaid, and Exchange (HIM) lines of business.
• Apply clinical judgment and pharmacy expertise to assess benefit configurations, clinical rules, and pharmacy setups for accuracy, safety, and compliance.
• Validate pharmacy benefit designs, including formularies, prior authorization criteria, step therapy, quantity limits, and utilization management logic.
• Interpret clinical documentation, policies, and regulatory guidance to ensure correct implementation within systems and operational workflows.

• Lead and co-lead end-to-end clinical and pharmacy benefit testing for new implementations, benefit changes, and remediation initiatives.
• Evaluate clinical program integrity, including medication therapy management, adherence programs, utilization management, and quality initiatives.
• Identify clinical and pharmacy risks, defects, and configuration gaps; document findings and drive resolution through cross-functional collaboration.

• Ensure testing outcomes align with CMS regulations, NCQA standards, and state-specific clinical and pharmacy requirements.
• Serve as a trusted advisor on regulatory interpretation, translating complex clinical and pharmacy guidance into actionable testing and configuration requirements.
• Support audits, client inquiries, and regulatory requests with defensible, clinically sound documentation and analysis.

• Analyze clinical and pharmacy data to identify trends, quality gaps, and improvement opportunities.
• Use data-driven insights to inform process improvements, control enhancements, and preventive quality strategies.
• Develop and maintain clinically focused quality controls, testing templates, and standardized procedures.

• Partner closely with Clinical, Pharmacy, Operations, PMO, Product, and Technology teams to ensure accurate execution of requirements.
• Communicate complex clinical and pharmacy concepts clearly to non-clinical stakeholders, including risks, impacts, and recommended actions.
• Mentor and train team members on clinical reasoning, pharmacy benefit structures, and regulatory expectations.
• Demonstrate leadership while managing multiple complex initiatives and maintaining high standards of quality and accountability.

Qualifications:

• Bachelor's degree strongly preferred; clinical, pharmacy, nursing, or healthcare-related background strongly preferred.
• Management experience required, with a demonstrated ability to lead and develop high-performing teams.
• Strong analytical, data management, and technical skills.
• Advanced proficiency with Microsoft Office Suite; experience with agile methodologies a plus.
• Excellent verbal and written communication skills, with the ability to explain complex clinical and pharmacy concepts clearly.
• Financial acumen and understanding of healthcare cost drivers preferred.

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. For this position, we anticipate offering an annual salary of 100,000 - 166,600 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

At The Cigna Group, you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, click here.

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you need a reasonable accommodation to complete the online application process, please email View email address on click.appcast.io for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.