Isabella Mburu
Anaheim,CA
Summary
Results-oriented Pharmacy Operations Specialist with over 13 years of experience in pharmacy benefit management (PBM), claims oversight, financial analysis, and formulary design. Skilled in assessing and modeling the financial impact of benefit design changes using tools like Excel and RxClaim. Proficient in stakeholder communication, data analysis, and process improvement. Collaborates cross-functionally to optimize PBM operations and ensure financial compliance in high-volume healthcare environments.
Overview
12
12
years of professional experience
Work History
Pharmacy Operations Specialist – Remote
Commonwealth Care Alliance
10.2024 - Current
- Performed data and claims review for financial accuracy and adjudication efficiency.
- Managed formulary submissions and supported PBM oversight for Commercial, Medicare, and Medicaid lines.
- Identified and resolved systemic configuration issues; supported transition claims analysis and reporting.
Pharmacy Referral & Recovery Coordinator
Prospect Medical Systems
06.2019 - 12.2024
- Reviewed high-cost injectable referrals and identified GPO-eligible drugs for cost savings.
- Conducted internal audits of drug claims; recovered overpayments and educated providers on billing best practices.
- Collaborated with IT to optimize claims adjudication logic and streamline financial edits.
Benefit Coordinator, Member Experience
Pinnacle Rx Solutions
06.2018 - 06.2019
- Processed and escalated benefit and claim issues, ensuring service level compliance.
- Assisted with intake and Prior Authorization workflow policies for pharmacy benefits.
- Provided support on FDA recalls, direct reimbursements, and client escalations.
Associate Pharmacy Benefit Implementation Analyst
OptumRx
12.2013 - 05.2018
- Implemented pharmacy benefits and pricing strategies using RxClaim and Excel macros.
- Worked with sales, clinical, and underwriting to resolve configuration and pricing logic issues.
- Supported claim adjudication testing, ensuring financial accuracy and regulatory compliance.
Education
B.S. - Clinical Operations & Healthcare Management
George Washington University
01.2024
Skills
- Financial Analysis
- Pharmacy Operations
- Claims Oversight
- PBM Systems (RxClaim, OptumRx, MedImpact)
- Excel (Advanced)
- SQL (Basic)
- PowerBI
- Formulary Management
- Process Optimization
- Audit & Compliance
- Healthcare Regulations
- SAP
- Project Support
- Cross-functional Team Collaboration
Timeline
Pharmacy Operations Specialist – Remote
Commonwealth Care Alliance
10.2024 - Current
Pharmacy Referral & Recovery Coordinator
Prospect Medical Systems
06.2019 - 12.2024
Benefit Coordinator, Member Experience
Pinnacle Rx Solutions
06.2018 - 06.2019
Associate Pharmacy Benefit Implementation Analyst
OptumRx
12.2013 - 05.2018
B.S. - Clinical Operations & Healthcare Management
George Washington University
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