FLORENCE MCKOY
Carson,CA
Summary
Accomplished Healthcare Administration and Pharmacy Operations Professional specializing in pharmacy benefits management, insurance adjudication, and regulatory compliance. Led high-performing teams while managing complex portfolios, enhancing customer service delivery in fast-paced environments. Demonstrated ability to build relationships, influence stakeholders, and provide strategic direction to achieve organizational goals.
Overview
16
16
years of professional experience
1
1
Certification
Work History
REMOTE LEAVE OF ABSENCE REPRESENTATIVE
Sedgwick
04.2024 - Current
- Manage a high-volume portfolio of complex FMLA, paid/unpaid state, military, and company-specific leave claims in a fully remote environment.
- Analyze medical documentation and complex case files to determine coverage eligibility, benefit certification, and payment calculations in strict compliance with federal, state, and client policies.
- Formulate targeted action plans and make time-sensitive case decisions by accurately interpreting detailed plan descriptions and regulatory guidelines.
- Communicate complex policy determinations, compliance requirements, and ongoing expectations clearly and professionally to claimants and corporate clients via phone, written correspondence, and claims management systems.
- Maintain top-tier client relationships and customer service metrics while handling sensitive, confidential information under strict HIPAA guidelines.
PHARMACY APPEALS COORDINATOR
Optum
Costa Mesa, USA
11.2020 - 08.2023
- Reviewed, processed, and coordinated formal requests for pharmacy benefits appeals, ensuring strict adherence to utilization management criteria and organizational quality standards.
- Compiled, audited, and synthesized comprehensive medical notes and clinical documentation from patients and healthcare providers to build objective case files.
- Conducted proactive outreach to providers, pharmacies, and patients to gather critical clinical data required to support coverage determination and appeal requests.
- Prepared, routed, and tracked complex appeal documentation through advanced review paths and clinical escalations.
- Communicated formal appeal denials and structural rationales clearly to patients and healthcare providers, ensuring transparency and meeting daily production and accuracy goals.
- Costa Mesa, CA
PHARMACY TECHNICIAN
Providence Medical Institute
08.2019 - 10.2020
- Prepared, submitted, and tracked clinical prior authorizations and referrals to insurance payers, driving timely approvals and minimizing patient care delays.
- Resolved complex pharmacy billing errors and third-party insurance rejections, coordinating refill requests with providers to enhance patient care continuity.
- Collaborated directly with providers and patients within a primary care clinic to identify and resolve complex medication access and insurance coverage issues.
- Assisted vulnerable patient populations in navigating and submitting medication assistance applications, co-pay cards, and financial aid programs, improving access to essential treatments.
- Initiated refill requests on behalf of patients to providers.
PHARMACY TECHNICIAN SUPERVISOR
Health Net
07.2010 - 11.2018
- Led, mentored, and managed a high-performing team of 16 pharmacy technicians, fostering a collaborative environment focused on accuracy and service excellence.
- Acted as the primary point of escalation for complex pharmacy, insurance, and customer service issues, successfully resolving conflicts to enhance member satisfaction.
- Directed interview, hiring, and onboarding processes for new team members, conducting structured monthly one-on-one performance reviews and coaching sessions to enhance team development.
- Monitored operational workflows, attendance, and payroll time sheets to ensure compliance with corporate policies and labor standards, contributing to overall operational integrity.
- Maintained current technical and pharmaceutical industry knowledge through participation in professional workshops and active engagement in daily department activities.
Education
High School Diploma -
Skills
- Leave Management
- Leave of absence management
- Prior Authorization (PA) Management
- Insurance Adjudication & Appeals
- Case Review
- Healthcare Administration
- Medical Terminology & Documentation
- HIPAA & Quality Assurance
- Team Leadership & Mentorship
- Pharmacy Benefits Management (PBM)
Certification
- Registered Pharmacy Technician License, 53039, California State Board of Pharmacy
- CPR / AED / First-Aid Certified, B7BDB1
Timeline
REMOTE LEAVE OF ABSENCE REPRESENTATIVE
Sedgwick
04.2024 - Current
PHARMACY APPEALS COORDINATOR
Optum
11.2020 - 08.2023
PHARMACY TECHNICIAN
Providence Medical Institute
08.2019 - 10.2020
PHARMACY TECHNICIAN SUPERVISOR
Health Net
07.2010 - 11.2018