Alexandra McDonough
Mc Kees Rocks,PA
Summary
Specialty Pharmacy professional with solid background in fostering strong relationships between pharmacies and clients. Proven ability to enhance pharmacy operations through effective collaboration and communication. Known for delivering high standards and driving impactful results. Valued for reliability and adaptability in dynamic environments.
Overview
13
13
years of professional experience
Work History
Specialty Pharmacy Liaison
ConnectiveRx
04.2024 - Current
- Working with specialty pharmacies to process referrals, manage data discrepancies, and generate weekly and monthly reports for the client on Specialty Pharmacy performance
- In addition, conduct weekly update calls and create and maintain an action log until all tasks are completed
- Manages the specialty pharmacy data and process on behalf of the manufacturer client; including, but not limited to requirements gathering and testing, processing patient enrollments, managing data discrepancies, managing client and specialty pharmacy inquiries, conducting weekly update calls with client contracted specialty pharmacies, data integrity, and providing weekly/monthly reporting to the client
- Works on complex issues where analysis of situations or data requires in-depth evaluation of variable factors
- Exercises judgment in selecting methods, techniques and evaluation criteria for obtaining results
- Networks with key contacts outside own area of expertise
- Completes and submits all necessary insurance forms and electronic claims in a timely manner as required by all third-party payors effectively utilizing various means for communication, including but not limited to phone, fax, mail, and online methods
- Provides exceptional customer service to internal and external customers; resolves any reimbursement trends/delays (e.g
- Billing denials, claim denials, pricing errors, payments, etc.)
- Verifies transactions and processes comply with organizational and departmental policies and procedures; suggests changes and solutions as appropriate
- Processes triage requests to Specialty Pharmacies
Service Advocate-Predictive Model Team
Aetna, a CVS Health Company
01.2020 - 11.2023
- Review post call and email surveys that received low scores from members
- Perform any service recovery to provide members with best experience
- Provide coaching and feedback to customer service reps based off call review
- Submit survey exceptions when needed
- Review and submit claims for rework
- Taking accountability to fully understand the member's needs by building a trusting and caring relationship with the member
- Filing grievances/appeals and following through the process
- Preventing complaints to Medicare
- Compliant with CMS guidelines
Customer Service Representative
Aetna, a CVS Health Company
06.2018 - 01.2020
- Answers questions and resolves issues based on phone calls/letters from members, providers, and plan
- Guides the member through their members plan of benefits, Aetna policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines
- Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health
- Taking accountability to fully understand the member's needs by building a trusting and caring relationship with the member
- Provides the customer with related information to answer the unasked questions, e.g
- Additional plan details, benefit plan details, member self-service tools, etc
- Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system
- Handles incoming requests for appeals and pre-authorizations
- Updates members Coordination of Benefits and sends claims for rework as needed
- Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received
Operations Team Manager
Alorica
08.2016 - 06.2018
- Provides regular supervision and mentorship over subordinate staff
- Ensure regular and effective communication with subordinate staff on performance, goals, and coaching
- Facilitates daily agent coaching and development sessions in both written and verbal format
- Participates in client related activities to include client calibration sessions and project planning
- Identify and address agent training needs
- Manage program specific performance standards (i.e
- AHT, Quality Scores, Sales, etc)
- Manage financial implications of attrition and attendance by maintaining program-specific goals
- Manage staffing in accordance with program specific workflow (i.e
- Down-staffing, up-staffing)
- Completion of weekly Team Manager Scorecard for review with Operations Manager
- Provide agent support via handling escalated calls, as needed
- Maintain up-to-date employee files and documentation
- Ensure high level customer service is being practiced by all subordinate Staff
Customer Advocate
Highmark Inc
04.2013 - 07.2015
- Resolves customer inquiries and complaints via written, telephonic, or face-to-face communication in a timely and accurate manner
- Prepares adjustments for services not properly processed, either systematically, or by forwarding to the appropriate area for follow up and resolution, such as claim adjustments or eligibility inquiries
- Meets all production, quality, and adherence standards
- Attends all required training classes
- Elevates issues to next level of supervision, as appropriate
- Maintains accurate records, including timekeeping records
- Other duties as requested
Provider Service Rep
Dial America
01.2012 - 01.2013
- Answering inbound calls pertaining to medical claims, member benefits, and eligibility
- Assisted the providers with information on why a claim was denied, information on paid claims, and how to send claims in to the insurance company
- Provided the members eligibility and benefits to the providers if needed
- Transferring providers or other callers to the correct department
- Documentation was required for all calls
- Programs used were MARx, Facets, Emdeon, and OnBase
- Knowledgeable in all programs and HIPAA
Education
Certificate - Patient Care Technician
Everest Institute
Pittsburgh, PA06.2009
High school diploma -
Cornell High School
Coraopolis, PA06.2008
Skills
- Customer service
- Detail-oriented
- Problem-solving skills
- Team management
- Clerical experience
- Microsoft office 365
- Communication and interpersonal skills
Timeline
Specialty Pharmacy Liaison
ConnectiveRx
04.2024 - Current
Service Advocate-Predictive Model Team
Aetna, a CVS Health Company
01.2020 - 11.2023
Customer Service Representative
Aetna, a CVS Health Company
06.2018 - 01.2020
Operations Team Manager
Alorica
08.2016 - 06.2018
Customer Advocate
Highmark Inc
04.2013 - 07.2015
Provider Service Rep
Dial America
01.2012 - 01.2013
High school diploma -
Cornell High School
Certificate - Patient Care Technician
Everest Institute
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