Jacqueline Candelario

Associate Manager specializing in regulatory compliance, complaints and appeals resolution, and policy interpretation within P&RA environments. Experienced in managing complex case reviews, ensuring adherence to federal and state regulations, and driving process improvements that enhance member experience and organizational compliance. Skilled in cross‑functional collaboration, root‑cause analysis, and delivering high‑quality, timely determinations.

• ERISA compliance — Managed complaints and appeals for self‑funded employer plans governed by ERISA, ensuring adherence to federal timelines, disclosure rules, and fiduciary standards.
• State insurance regulations — Processed fully insured plan cases in alignment with state‑specific grievance and appeal laws, DOI requirements, and mandated turnaround times.
• Dual‑framework navigation — Interpreted and applied both federal (ERISA, ACA) and state regulatory requirements depending on plan funding type.Funding‑type case handling — Distinguished between self‑funded and fully insured plan rules to ensure accurate, compliant determinations and proper escalation pathways.
• Employer‑specific plan rules — Reviewed SPD and plan documents for self‑funded groups to ensure determinations aligned with employer‑defined benefits.
• State‑mandated processes — Applied state‑required appeal levels, member rights, and notification standards for fully insured plans.

Results‑driven Pharmacy and Claims Supervisor with experience directing high‑performing teams in fast‑paced healthcare operations. Skilled in overseeing daily workflows, coaching staff, and ensuring accurate processing of pharmacy cases, medical claims, coverage determinations, grievances, and appeals across Medicare, Medicaid, Commercial, self‑funded, and fully insured plans.

• Supervised pharmacy and claims teams, provided daily direction and coaching to enhance team performance and maintain service consistency.
• Managed scheduling to optimize coverage during peak call times, ensuring team availability for customer inquiries.
• Led team huddles, one‑on‑ones, and performance discussions to reinforce expectations and maintain accountability.
• Trained staff on pharmacy benefit rules, claims adjudication, coverage determinations, and regulatory requirements.Monitored key performance indicators including accuracy, productivity, turnaround times, and compliance metrics.
• Developed training materials to enhance team performance and service quality.
• Collaborated with management to implement process improvements for efficiency.
• Resolved escalated customer complaints promptly, enhancing customer satisfaction and loyalty.