Angelica Walker
Summary
Highly talented with 15 years of experience. Utilization management professional with proven expertise in prior authorizations, appeal screening, training, leadership and quality. Focused on team collaboration and achieving impactful results. Skilled in specialty pharmacy, healthcare, customer service, prior authorizations and appeal criteria. Reliable, adaptable, and consistently meets changing organizational needs.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Utilization Management Representative II(Appeals)
Elevance Health
03.2023 - Current
- Facilitated optimal resource allocation by analyzing trends in service utilization and identifying areas for improvement.
- Promoted a culture of collaboration and teamwork, fostering an environment that encouraged open communication and shared learning among colleagues.
- Reduced wait times for essential services by effectively managing utilization review caseloads and prioritizing urgent requests.
- Evaluated medication guidelines and benefit coverage to determine appropriateness of services.
- Optimized the delivery of healthcare services by staying current on emerging trends and developments in the field of utilization management.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Provides Quality control services for prior authorization reps
- Keeps team members and other managers informed of any changes in screening criteria
- Suggests methods to improve PA quality and productivity
- Assists management by identifying areas of improvement and recommends solutions
- Handles escalations and provides assistance to less experienced reps
- Understands workflow, processes, departmental priorities and guidelines for prior authorization and appeals
- Assists with keeping departmental manuals up to date and sharing with appropriate teams
- Motivates and encourages UM reps while providing quality guidance
- Devise or identify solutions for irregular requests and issues.
- Evaluates patient histories, complaints, and current symptoms.
- Appeal screener point of contact for white glove account
- Collaborated with leadership to devise initiatives for improving prior authorization and appeal approvals rates, retention and morale.
- Collaborated with subject matter experts to create accurate training content.
- Created and oversaw appeal screening training documentations for reps
- Assisted in the development of targeted strategies aimed at reducing unnecessary service usage without compromising quality of care.
- Performed prior authorization review of services requiring notification.
- Served as a liaison between patients, healthcare providers, and insurance companies to facilitate timely appeal screening review of requested medications
- Assists with meeting Appeal approval rates by screening prior auth denials for appeal eligibility.
Admissions Enrollment-Certified Pharmacy Technician
BioPlus Specialty Pharmacy
11.2019 - 03.2023
- Expedite prescription processing by performing all duties necessary and allowable, by policy or law
- Maintain inventory analysis
- Verify insurance for limits and parameters of policy
- Determine if prior authorization or precert is necessary and work accordingly
- Submit Prior Authorizations or Precerts
- Input required patient data information into system
- Create verification notes explaining benefits and other necessary information
- Process/reverse online claims
- Responsible for maintaining spreadsheets
- Review benefits with appropriate personnel
- Advise Pharmacy staff of any new drugs
- Communicated directly with doctors offices via telephone, fax and email.
- Update Sales staff with pertinent information
- Communicated with prescribers to verify medication dosages, refill authorizations, and patient information.
- Collaborated with pharmacists to resolve medication-related issues, optimizing patient outcomes.
- Proactively addressed potential conflicts or discrepancies within the pharmacy team to maintain a positive work environment.
- Coordinated communication between healthcare professionals to ensure seamless patient care transitions between providers or facilities.
- Identified areas for improvement in workflow processes and implemented changes that led to increased efficiency within the pharmacy.
- Performed wide range of pharmacy operations with strong commitment to accuracy, efficiency and service quality.
- Enhanced patient care by accurately entering prescriptions in a timely manner.
- Assisted in training new employees, sharing tips for efficient data entry techniques.
- Handled rx data entry and other related work for supervisors and program managers.
- Reduced data entry errors, ensuring thorough verification of entered information against source documents.
Medication Adherence Pharmacy Technician
HealthFirst
10.2017 - 11.2019
- Make outbound calls and Receives inbound calls to/from members regarding medication adherence
- Assists members regarding medication adherence barriers such as copay, transportation, Doctor Appointments
- Collaborate with pharmacists to assist members regarding side effects and other medication concerns
- Contact pharmacies to refill member's medication, DS requests, refill rx requests and Med Sync
- Motivate members and provides assistance with getting them back adherent with medication therapies
- Train New hires
Pharmacy Technician/SME/Data Entry Trainer
CVS Specialty Pharmacy
02.2016 - 09.2017
- Coordinated and processed new and refill orders
- Assisted in enrolling and tracking statuses of new customer referrals and with initiation of therapy
- Resolved financial and operational issues in collaboration with other pharmacy staff, admissions and reimbursement
- Translated and enters prescriptions
- Inputted and processes medications through insurance
- Assisted with administrative and operational duties as required
- Worked with VIP accounts and the handling of specific drugs
- Data Entry Liaison
- Served as back up for lead by providing day to day resources and assignments to others
- Helped train and mentor other PSRS
- Trained new hires in Data Entry and Various Work-List Processes (Class sizes 14-25)
- Created Work-List and Training Documents and Reference Pages
- Escalated clinical questions and issues to the staff pharmacist for resolution
- Maintained medical profiles
- Handled escalated calls from other representatives
- Assisted my colleagues with questions (POC for assistance)
Pharmacy Technician Lead / Customer Service Representative
Accredo Specialty Pharmacy
09.2009 - 08.2015
- Answered phone calls on the inbound queue and made outbound calls
- Contacted physician offices for new prescriptions, refill prescriptions, clarifications and dosage changes
- Handled escalated emails from customers and Doctor Offices
- Ensured that all prescriptions were attached to the correct patient's account
- Worked with VIP accounts and the handling of specific drugs
- Appointed Point of Contact when Supervisors were unavailable
- Prescription entering and processing
Education
Associates Degree -
Valencia College
Orlando, FL01.2015
Pharmacy Technician -
Lincoln Technical Institute
Fern Park, FL01.2009
Pre-pharmacy Major -
Bethune Cookman University
Daytona Beach, FL01.2008
High School Diploma -
Edgewater High School
Orlando, FL01.2007
Skills
- Critical thinking
- HIPAA compliance
- Professionalism and ethics
- Claims processing
- Time management mastery
- Resourcefulness and initiative
- Goal oriented approach
- Decision making aptitude
- Utilization review expertise
- Medical terminology proficiency
- Clinical assessment
- Quality improvement
- Documentation and reporting
- Interpersonal and written communication
- Teamwork
- Problem-solving
- Multitasking Abilities
- Compassionate and caring
- Reliability
- Excellent communication
- Strong clinical judgment
- Organizational skills
- Team collaboration
- Microsoft office
- Professionalism
- Goal setting
Certification
Registered pharmacy technician(FL)
Training
Pharmacy Technician Extern, Taylor’s Pharmacy, Winter Park, FL, 06/01/09, 08/01/09, Insurance Online Adjudication, Basic IV, Aseptic Technique, Basic Compounding, Customer Service, Data Processing, Inventory Management, Interpret Medication Orders, Prescription Filling
Timeline
Utilization Management Representative II(Appeals)
Elevance Health
03.2023 - Current
Admissions Enrollment-Certified Pharmacy Technician
BioPlus Specialty Pharmacy
11.2019 - 03.2023
Medication Adherence Pharmacy Technician
HealthFirst
10.2017 - 11.2019
Pharmacy Technician/SME/Data Entry Trainer
CVS Specialty Pharmacy
02.2016 - 09.2017
Pharmacy Technician Lead / Customer Service Representative
Accredo Specialty Pharmacy
09.2009 - 08.2015
Pharmacy Technician -
Lincoln Technical Institute
Pre-pharmacy Major -
Bethune Cookman University
High School Diploma -
Edgewater High School
Associates Degree -
Valencia College