Christina LaMarche

• Company Overview: OPTUMRX BOUGHT CASTIA RX
• Perform comprehensive medication reviews (CMRs) in accordance with plan/Medicare guidelines and regulations
• Work as part of the clinical services call center, taking inbound/autodialer calls and making outbound calls with the goal of meeting or exceeding the STAR goals
• Collaborate with members/family to identify the medications they are taking for the conditions that they have
• Identify drug allergies, interactions, improper dosing of medications and provide medication education and recommendations based on standard guidelines for specific health conditions and documenting in the electronic record
• Duties also include calling facilities and physician offices when appropriate to complete reviews or to address any serious medication issues the member may have

• Company Overview: PTI-NPS merged to create Castia RX
• Performed CMRs as noted above
• Other duties included communicating and collaborating with plan representatives to identify and meet plan goals, share current demographic information, and work to identify and address member issues and grievances in a timely fashion
• Completed monthly Quality Assurance (QA) tasks, collaborated with other departments as needed
• Compilation and review of data for year-end submissions to plans and Medicare, and management of Long-Term Care (LTC) member lists to reach desired STAR ratings

• Reviewed of Part A and Part B of A Medicare appeals to determine payment for medically necessary and appropriate services in compliance with Medicare regulations
• Trained and completed reviews of many types of claims to include inpatient rehabilitation facility, acute short-term hospital, diagnosis related group changes, therapies (physical, occupational and speech), skilled nursing facility, lab work, medically unlikely edit, and miscellaneous Part B of A services
• Assisted in training new staff, development of documentation tools and production expectations

· Triaged patients via phone per Milliman and then InterQual guidelines, assisted with patient care/procedures in clinic, managed patient messaging via portal and maintained ongoing communication with patients regarding their healthcare.

Utilized various computer programs including EMR and military health care database.

· Specialty clinics/populations: Coumadin clinic duties four hours per month and as needed after specialized training; worked with special duty military patients to manage their health care needs; performed medical briefings and chart review for incoming active duty members.

· Worked as Disease Management Nurse and collaborated with various departments/providers to ensure military member and family health care needs were promptly identified, addressed and documented.

· Collaborated with provider to establish and run a pilot program for Diabetes education classes and 1:1 teaching for diabetic patients, documented and monitored results of this new program.