Brikeila McDade

• Process and evaluate healthcare utilization requests, implementing evidence-based protocols to optimize patient care outcomes while maintaining compliance standards
• Review medical documentation and coordinate with healthcare providers to ensure appropriate resource allocation and service authorization
• Partner with clinical teams to streamline utilization management workflows, reducing processing time while maintaining quality standards via Slack
• Support all lines of business via facilitating the process for utilization management and entering authorizations into claims platform via data entry
• Facilitate communication between providers and insurance teams, ensuring timely resolution of authorization requests and patient care needs

• Partnered with insurance providers to obtain prior authorizations, resolve claim processing issues, and reconcile patient payments
• Reviewed and analyzed patients’ insurance benefits to determine eligibility and co-pay costs for prescribed medications.
• Triaged and resolved patient grievances through root cause analysis and implemented simple solutions to solve complex problems
• Educated patients on discounts and promotions from internal and external parties to minimize financial obligations.
• Supported customers both in-person and via remote applications, including multi-line telephone calls, video, and email
• Maintain compliance with strict HIPAA guidelines, FDA standards, and industry regulations for controlled substances

• Advised patients on medication instructions, side effects, and directions to increase compliance with physician orders
• Liaised between patients, providers, and insurance companies to facilitate conversations surrounding prescription concerns
• Served as a Subject Matter Expert on medication refills, renewals, basic billing inquiries, and procedural pharmacy activities
• Spearheaded all patient referrals and communicated with patients to collect information regarding medical conditions
• Performed outbound calls to providers and pharmacies
• Updated patient's medical records

Cultivated strategic relationships with company executives and key personnel to improve cross-functional communication

• Directed supplemental training on the use of company portals and electronic records management software to VA staff
• Researched and resolved provider network issues, credentialed providers, and authorized veteran medical referrals
• Contacted providers for VA Community Care Network Department
• Provided network contracts to providers
• Received, reviewed, and uploaded provider contracts via Sharepoint
• Maintained updated credentialing with providers to ensure contracts were in compliance
• Issued notification to providers when there was a lapse in compliance
• Ran reports and responded to inquiries regarding contract compliance issues
• Constructed excel spread sheets with updated provider network providers
• Responded to provider complaints and researched claim and network issues
• Researched veteran's medical referrals as requested by VA staff
• Collaborated with cross-functional teams to enhance providers onboarding processes and experience.
• Executed regular follow-ups with VA Community Care Dept to ensure ongoing engagement and address concerns promptly.
• Enhanced client satisfaction by promptly addressing concerns and providing tailored solutions.
• Built strong relationships with VA staff through consistent communication, understanding their needs, and delivering on expectations.
• Acted as a liaison between VA Community Care Dept and internal teams, effectively communicating client needs to ensure timely and successful delivery of referrals

• Built high-performing teams of Pharmacy Technicians and oversaw the training and mentorship of 20+ junior technicians
• Designed and implemented a training manual to provide instruction on best practices, regulatory affairs, and FDA guidelines
• Delivered world-class customer service for prescription orders with dignity and respect to all customers
• Collaborated with care members and providers to provide access to care and meet the needs of each client
• Reviewed computer medication profiles for therapeutic duplication, prescription non-compliance, and allergies or drug reactions
• Documented patient contacts, inquiries, and call resolution in company software and electronic healthcare records
• Spearheaded inventory management, including verifying quantities, overseeing ordering, and removing expired medications
• Maintained files and computer records for pharmacy
• Communicated with prescribers to verify medication dosages, refill authorizations, and patient information
• Counted, measured, and compounded medications following standard procedures