Cynthia Goertz

1995: Member of Pharmacy Help Desk (Call Center) team – maintained coverage of toll-free ACD 1-800 MEDICAID/CHIP help desk. Provided first line resolution to pharmacies, physicians’ offices, Medicaid recipients and software providers to resolve problems associated with inquiries on Electronic Claims Submissions, Client Eligibility, Product coverage and limitations, Drug Utilization Review (DUR) rejections, Prior Authorizations, Provider Contracts, Software problems.

Identified Medicaid, Children with Special Health Care Needs (CSHCN) and Kidney Health Care (KHC) pharmacy claims processing errors. Directed appropriate adjudication of claims which included payment of incorrectly denied claims, and/or recoupment of misspent Medicaid monies with the authority to override pharmacy claims system edits.

Provided verbal and written interpretation of Medicaid, CHIP, CSHCN and KHC rules, regulations, policies and procedures. Interpreted policies and procedures of the Vendor Drug, CHIP, CSHCN and KHC pharmacy programs.

Tracked inquiries by caller, Client, problem type, program type and resolution code by logging all ACD calls into the on-line tracking system – MS Dynamics CRM.

September 2012: Selected to be a member of the Vendor Drug Program (VDP) Pharmacy Benefits Access (PBA) Issues Escalation Team. Worked as Subject Matter Expert (SME) in pharmacy claims adjudication, pharmacy knowledge and call center operations. Trained and ensured pharmacy call center staff provided exceptional customer service to pharmacy providers. Monitored calls, pulled call stats reports using Cisco Unified Intelligence Center software, MS CRM software. Researched and provided resolution of escalations received at the pharmacy provider level using Conduent’s PBM OS+ claims processing system.

October 2017: The PBA section of the Vendor Drug program was transferred to Managed Care Compliance and Operations, (MCCO) now called Managed Care Contract Oversight. Primary back up coverage for call center. Continued role as SME for pharmacy complaints, help desk oversight, develop policies and procedures for call center staff. Primary contact and tester for new pharmacy related implementations related to the call center Cisco Finesse call system/Lumen and Vendor Drug Pharmacy implementations for PBA. Research and provide resolution to issues escalated from the pharmacy call center staff and the office of the Ombudsmen including but not limited to pharmacy prior authorization approvals and denials, rejected pharmacy claims and Medicaid policy. PBA SME for the Vendor Drug Pharmacy VPM Modernization transition.

• Stocked, labeled and inventoried medication to keep accurate records.
• Maintained drug inventory levels by ordering necessary medications and supplies.

prepared unit dose packaging of medication for patient care homes for the school, delivered prescription medications to nursing stations and inspected medication rooms for the correct storage of prescription drugs and the proper documentation on medical charts of prescription regimens and dose compliance. Purchasing and inventory control management. Filled residents’ prescriptions for Pharmacist review – pulled prescription drugs, counted units, verified does and packaged based on directions.

· Certified Pharmacy Technician: was responsible for the electronic processing of pharmacy claims. This included, but not limited to, verifying eligibility, drug coverage and the data entry process of completing a Medicaid claim and other third parties.

· Calculated the days supply, dosage and quantity for prescriptions in preparing medications for the Pharmacist to label.

· Responsible for handling multiple phone lines while resolving issues for customers, client and third parties, calling doctor offices for refill requests.

· Contacted various insurance companies and or Pharmacy Benefit Managers regarding pharmacy claim rejects.

· Responsible for the training of new employees to include how to operate the Walgreen’s electronic claim processing system and to research Medicaid and other third-party claims.