Deborah L. Fish
Wickenburg
Summary
Detail-oriented Quality Auditor with extensive experience in analyzing contracts and processes within the pharmacy and insurance sectors. Proven ability to cultivate positive client relationships while demonstrating strong prioritization and problem-solving skills. Expertise in conducting thorough audits to ensure compliance with regulatory standards, utilizing analytical skills to identify risks, enhance internal controls, and improve audit processes. Proactive and goal-oriented professional recognized for reliability and adaptability, committed to leveraging these strengths to drive team success and contribute to organizational growth.
Overview
8
8
years of professional experience
1
1
Certification
Work History
Quality Review and Audit Lead Representative
Evernorth
05.2023 - Current
- Audit accuracy of client contracts build into the ePro database for accuracy.
- Manage audit activity assigned meeting all key deliverables inclusive of turnaround times, communicating and documenting corrections, and providing projected completion of commitment dates.
- Document findings in appropriate Cigna quality repository ensuring documentation is clear and concise.
- Identify and recommend improvements in department processing and procedures and assist in the development of audit guidelines.
- Actively engage in quality initiatives to address error trends and process improvement.
- Assist as a SME in SOC audits, AI Bot QUIC Tool mapping, Focused/Super Audits.
Quality Review and Lead Representative
Accredo Health Group Quality
03.2020 - 01.2023
- Perform call audits to ensure business standard quality is provided to our internal/external partners and our patients’.
- Perform process audits to ensure SOPs are being followed to avoid negative impact to our patient, external partners’, and our company.
- Setup and lead WebEx EQM meetings with operation team supervisors to discuss trends using Microsoft Excel data reports and brainstorm ideas to better assist the employees in improving their overall metric scores.
- Participate in collaborations with peers to ensure alignment within the role.
Eligibility Senior Representative
Accredo Health Group Pharmacy
07.2019 - 03.2020
- Performs all aspects of electronic claims process and rejection resolutions.
- Ensures accounts requiring authorizations and re-authorizations are identified, secured, and updated in the system.
- Contact benefit providers to gather policy benefits and limitations to ensure services provided will be reimbursable such as deductible amounts, co-payments, effective dates, and levels of care.
- Utilize the Standard Operating Procedures to ensure the process is done accurately to avoid potential future issues with the customer and/or company.
- Communicate insurance requirements and pathways to resolution with patients and providers.
Specialty Pharmacy Technician
Cigna Specialty Pharmacy
08.2018 - 07.2019
- Process specialty pharmacy medications under established guidelines; provide detailed documentation via internal and external systems.
- Use various computer applications both internal and commercial to perform item entry tasks, verify eligibility, and set up patient shipments.
- Work in various claims processing systems.
- Walk orders through the system as needed for STAT deliveries.
Customer Service Representative Associate
Cigna Pharmacy Services
05.2017 - 08.2018
- Respond to phone, fax, and online prior authorization inquires from health care professionals.
- Initial screening of requests with the use of online prior authorization tools for guidance.
- Approve prior authorizations requests if the data collected meets the approval specifications.
- Participated in the Quality Action Team formed to brainstorm ideas on ways to increase the quality of our work that would affect our customer’s experience.
Education
GED -
Northland Pioneer College
Skills
- Strategic thinking
- Coaching and mentoring
- Data analytics
- Problem-solving
- Communication (written and verbal)
- Time management
- Team collaboration
- Adaptability
- Quality Assurance & Auditing
- Microsoft Office Suite (Excel, Word, Outlook)
- Attention to detail
Accomplishments
- Collaborated with IT to implement AI QUIC tool, reducing manual entry errors.
- Assisted as a SME with OTJ training new hires.
Certification
- Certified in Medical Terminology and Transcription
- Some studies in the Cigna Focus Skills on Conflict Management
- Technology Enrichment Class for Excel Formulas and Pivot Tables.
Languages
English
Timeline
Quality Review and Audit Lead Representative
Evernorth
05.2023 - Current
Quality Review and Lead Representative
Accredo Health Group Quality
03.2020 - 01.2023
Eligibility Senior Representative
Accredo Health Group Pharmacy
07.2019 - 03.2020
Specialty Pharmacy Technician
Cigna Specialty Pharmacy
08.2018 - 07.2019
Customer Service Representative Associate
Cigna Pharmacy Services
05.2017 - 08.2018
GED -
Northland Pioneer College
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