Manage the pharmacy plan administration team with benefit requests, plan design implementation, termination and data transfer requests and escalated issues to ensure successful claims readiness.
Complete internal mapping of prescription drug plans and work with PBM to assure correct benefits are applied for Commercial, Self Funded, Exchange and Medicare lines of business.
Oversee daily eligibility and accumulator files.
Oversite of plan benefit auditing completed to assure claim adjudication is as intended.
Generate scheduled and ad hoc reporting requests.
Establish cross-department relationships to ensure accuracy and success of all plans and pharmacy administration initiatives.
Conduct root cause analysts, gathering data to pin point problem areas within benefit and formulary administration landscape.
Show ability to perform claim analysis to find and solve programming errors within PBM software.
Guide the plan administration team with audit protocols, benefit validation and core testing processes.
Assist internal teams with the development and implementation of new operation controls and pharmacy programming initiatives.
Ensure business partner's accountability for the accurate and timely completion of benefit designs and clinical rule/criteria changes.
Work in conjunction with PBM to develop, monitor and improve operation controls and pharmacy program initiatives.
Develop unit policies and procedures as applicable and ensure their regular maintenance to reflect new practice and guidance.
Provider pharmacy operational troubleshooting and resolve issues related to eligibility, claims and benefit setup.
Generate and analyze reporting for new and transitioning groups.
Assist with development of team goals, providing team support and creating training documents to assist with team growth and development.
Proactively educate and provide recommendations to avoid future service issues (benefit, implementation, formulary and product changes).
Assist the VP of Pharmacy Services with development of new programs, or changes to improve or provide solutions for current work processes.
Coordinate special projects according to Pharmacy's VP general instructions related to more complex and detailed projects.
Complete regular testing to assure that pharmacy benefits are compliant with applicable federal and state mandates.
Take part in client calls to assist with questions and concerns related to pharmacy benefits.
Pharmacy Benefit Analyst
The Health Plan
04.2019 - 07.2023
Completed quality assurance and testing of PBM functions related to claims adjudication, reporting and plan setup.
Prepared detailed reports on benefits expenditures, informing management of financial impacts associated with each plan offering.
Assist with implementation of new plan setups.
Process benefit requests, terminations and escalated issues to ensure successful claims readiness.
Conduct root cause analysts to pinpoint problem areas within the pharmacy benefit structure.
Work together with PBM to monitor operational controls related to benefit setups.
Generated scheduled and ad hoc reporting requests.
Tested to ensure benefit setups were compliant with applicable state and federal laws.
Troubleshooted and resolved issues related to eligibility, claims and benefit setup.
Certified Pharmacy Technician
The Health Plan
04.2016 - 04.2019
Trained new pharmacy technicians on proper procedures and best practices, ensuring consistent quality of service.
Answered incoming phone calls and addressed questions from customers and healthcare providers.
Completed medication coverage requests through prior authorization criteria and escalated requests to Clinical Pharmacist when requests required clinical review or were not approvable through automated system.
Contacted providers to obtain necessary and/or additional information for coverage requests.
Resolved and documented coverage request outcomes in PBM's system and communicated decision to physician's office and/or members through verbal and/or written notification in accordance with company policy.
Provided verbal verification of member's plan eligibility and applicable pharmacy benefits.
Provided requested details to members and pharmacies in relation to formularies and networks.
Assist pharmacies in processing prescription claims; reviewed and troubleshooted claims processing issues.
Explain appeal and grievance process to member and providers.
Handle calls and correspondence after hours when scheduled.
Certified Pharmacy Technician
Wheeling Hospital
04.2013 - 04.2016
Answered incoming phone calls and addressed questions from customers and healthcare providers.
Calculated dosages, filled prescriptions and prepared prescription labels with absolute accuracy.
Counted and labeled prescription with correct item and quantity.
Stocked, labeled and inventoried medication to keep accurate record.
Communicated with patients to collect information about prescriptions and medical conditions or arrange consultations with the pharmacists.
Entered and processed patient's prescriptions into internal system.
Solved customer problems in person or over telephone by providing assistance with placing orders, navigating system and locating items.
Consulted with insurance company representatives to complete claims processing, resolve concerns and reconcile payments.
Restocked pharmacy shelves with current merchandise to drive consistent peripheral sales.
Counted, measured and compounded medication following standard procedures.
Ordered medicines daily to replenish stock and increase inventory in anticipation of need.
Certified Pharmacy Technician
Kroger
11.2009 - 04.2013
Answered incoming calls and addressed questions from customer and healthcare providers.
Calculated dosage, filled prescriptions and prepared prescription labels with absolute accuracy.
Counted and labeled prescriptions with correct item and quantity.
Stocked, labeled and inventoried medication to keep accurate records.
Performed various pharmacy operational activities with strong commitment to accuracy, efficiency and service quality.
Maintained proper drug storage procedures, registries and records for controlled drugs.
Collected co-payments or full payments from customers.
Consulted with insurance company representatives to complete claims processing, resolv concerns and reconcile payments.
Education
High School Diploma -
John Marshall High School
Glen Dale, WV
05.2007
Skills
Team Leadership
Time Management
Complex Problem-Solving
Data Analysis
Excel Functions
Drug Classification Knowledge
Compliance Monitoring
Power BI Tools
Multi-Tasking Aptitude
Self-Motivated Learning
Certification
CPhT - Certified Pharmacy Technician
State of WV Insurance Producer License (Accident and Health or Sickness, Life)
Timeline
Pharmacy Account Management, Manager
The Health Plan
07.2023 - Current
Pharmacy Benefit Analyst
The Health Plan
04.2019 - 07.2023
Certified Pharmacy Technician
The Health Plan
04.2016 - 04.2019
Certified Pharmacy Technician
Wheeling Hospital
04.2013 - 04.2016
Certified Pharmacy Technician
Kroger
11.2009 - 04.2013
High School Diploma -
John Marshall High School
CPhT - Certified Pharmacy Technician
State of WV Insurance Producer License (Accident and Health or Sickness, Life)
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