Jillian Malcolm
Buffalo,NY
Summary
Take-charge professional delivering executive support and team leadership to business operations. Dependable and detail-oriented to manage multiple tasks and priorities. Broad experience includes working in all aspects of the Health Insurance Industry including but not limited to enrollment, accounts receivable, compliance, product, regulatory compliance oversight and implementation, vendor and delegation oversight and implementation and pharmacy and PBM operations. Recognized as a strong change agent with a strength in identifying issues and finding to be the best solution. Experienced leader with a strong record of success in associate development.
Overview
16
16
years of professional experience
Work History
Director, Pharmacy Services and Operations
Independent Health Association, Inc.
08.2019 - Current
- Develops strategies, goals, and plans for assigned functional areas within the pharmacy department
- Provides leadership and direction to pharmacy operations teams including all Pharmacy Services, Operations and Compliance, Training and Quality
- Develops scorecards and metrics to ensure operations are meeting specified performance standards and targets
- Serves as key point of contact for pharmacy compliance/regulatory activities in audit and new requirement implementations
- Serves as a liaison between pharmacy providers, PBM clients and pharmacy department staff
- Represents the pharmacy department at various internal and external meetings related to pharmacy/PBM operations and develop analyses to support business decisions
- Coordinates and oversight of special projects and other duties as necessary
- Oversees and manages the formulary process
- Oversees operational pharmacy delegated services to vendors and/or affiliates
- Designs, develops, and implements new operational policies and procedures and periodically reviews and revises existing operational policies and procedures
- Facilitates integration of Pharmacy benefits to provide efficient patient centered care and operational efficiency
- Provides oversight accountability for all internal and external communications for Pharmacy initiatives to members, providers, and pharmacies.
Manager, Pharmacy Operations
Independent Health Association, Inc.
08.2017 - 08.2019
- Develops scorecards and metrics to ensure operations are meeting specified performance standards and targets
- Serves as key point of contact for pharmacy compliance/regulatory activities in audit and new requirement implementations
- Designs, develops, and implements new operational policies and procedures and periodically reviews and revises existing operational policies and procedures
- Facilitates integration of Pharmacy benefits to provide efficient patient centered care and operational efficiency.
Manager, Government Programs Compliance
Independent Health Association, Inc.
01.2017 - 08.2017
- Assess, communicate, and track government program regulations through completion and/or implementation
- Develop and manage a risk-based monitoring program for government programs compliance operations across operational departments (i.e
- Claims, enrollment, and network management)
- Develop and oversee a pharmacy-specific government product quality and monitoring program of prior authorization and PBM activities focused on pharmacy rejections, paid claims, and coverage determinations
- Assist with formulary development and provide decision support to Medicare product bid, pharmacy services, clinical pharmacists, the Pharmacy and Therapeutics Committee, and medical directors
- Review and assess policy and procedures to ensure compliance with all regulatory requirements
- Facilitate and support all government program-related audits, including Data Validation (DVA), CMS Program Audit, DOH audit activities, CHP annual financial and program audits, mock audits, PDE, formulary administration, transition, and website
- Review and facilitate training programs
- Management of the current Government Pharmacy Programs and QA team
- To establish, implement, and monitor personnel practices related to working hours, conduct while working, and documentation of appropriate events
- Help develop, coach and advise associates as necessary.
Government Programs Compliance Manager
Independent Health Association, Inc.
04.2015 - 01.2017
- Ensured effective execution and oversight of the regulatory implementation on behalf of Independent Health's government programs, assisting with prioritization, risk management and execution of key business processes required to follow state and federal requirements
- Participated in all audit activity, providing insight from both compliance and operational perspectives
- Developed compliance policies, procedures and documentation for new laws, rules and regulations and coordinated with pertinent departments to gather, assess content of, catalogue and tabulate documentation related to compliance.
Product Operations Specialist
Independent Health Association, Inc.
03.2014 - 04.2015
- Facilitated all Medicare compliance activities within the Medicare Operations team, including the tracking of all Medicare policies and procedures, completion of the annual CMS readiness assessment, coordination of the annual compliance and FWA training for Medicare Operations vendors, and representing Medicare Product Operations at the Medicare Compliance Committee and Product Operations Policy and Procedure team
- Completed daily, weekly and monthly monitoring of high-risk processes including creditable coverage mailings, new member kits, ANOC and EOC mailings, and ID card mailings
- Managed the implementation of a new Medicare plan with the PBM, representing Medicare Operations to ensure compliance and timely task completion.
QA coordinator, Medicare Product Management
Independent Health Association, Inc.
04.2013 - 03.2014
- Monitored operational compliance with Medicare requirements, reviewed and assisted with the implementation of regulatory policies and procedures, coordinated vendor FWA and compliance training, and oversaw annual production of membership contracts (ANOC/EOC) according to CMS requirements
- Presented regulatory changes to departments throughout the organization, working with teams to help with changes and understanding the product/line of business.
QA coordinator, Medicare Revenue
Independent Health Association, Inc.
04.2011 - 04.2013
- Implemented a new billing and enrollment system, writing requirements, policies and processes based on Federal and State requirements and internal policies
- Performed quality assurance for existing and new systems and tested system changes and upgrades
- Collaborated with Business Analyst to write all necessary requirements needed to configure systems according to business needs and regulatory requirements.
Supervisor Membership Operations, Medicare Enrollment
Independent Health Association, Inc.
07.2010 - 04.2011
- Managed production output and quality, producing a weekly dashboard report, monitored Medicare changes and HPMS reporting
- Supported Customer Service and Group Account Services with all incoming escalated member, group, and billing issues
- Supervised staff of 7, performing quarterly reviews, managing schedules, training staff on system and Medicare changes, and triaging employee questions.
Medicare Resolutions Specialist
Univera Health Care
04.2009 - 07.2010
- Reconciled billing adjustments due to low income status or EPIC adjustments, worked the LIS TRR, Acumen reports, and other CMS files to ensure billing discrepancies are resolved timely.
Medicare Enrollment Processor
Univera Health Care
12.2007 - 04.2009
- Worked with the Enrollment team to ensure all enrollments, reinstatements, and plan changes were verified and processed according to regulatory requirements.
Education
Nursing Education
Erie Community College
Buffalo, NYSkills
- Business Development
- Operations Management
- Strategic Planning
- People Management
- Cross-Functional Team Leadership
- Legal and Regulatory Compliance
- Creativity and Innovation
Timeline
Director, Pharmacy Services and Operations
Independent Health Association, Inc.
08.2019 - Current
Manager, Pharmacy Operations
Independent Health Association, Inc.
08.2017 - 08.2019
Manager, Government Programs Compliance
Independent Health Association, Inc.
01.2017 - 08.2017
Government Programs Compliance Manager
Independent Health Association, Inc.
04.2015 - 01.2017
Product Operations Specialist
Independent Health Association, Inc.
03.2014 - 04.2015
QA coordinator, Medicare Product Management
Independent Health Association, Inc.
04.2013 - 03.2014
QA coordinator, Medicare Revenue
Independent Health Association, Inc.
04.2011 - 04.2013
Supervisor Membership Operations, Medicare Enrollment
Independent Health Association, Inc.
07.2010 - 04.2011
Medicare Resolutions Specialist
Univera Health Care
04.2009 - 07.2010
Medicare Enrollment Processor
Univera Health Care
12.2007 - 04.2009
Nursing Education
Erie Community College
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