Karla Rodriguez Rivera

•Lead management of MedPharm escalation tickets, collaborating with cross-functional teams to ensure timely resolution of high-priority customer and provider issues.
•Drive continuous improvement initiatives by analyzing error trends, identifying process gaps, and presenting actionable insights to leadership to enhance accuracy and efficiency.
•Support Health Plans, PA Ops, and Call Center teams with resolving prior authorization issues, including incorrect or untimely reviews, letter corrections, and override discrepancies.
•Analyze ServiceNow trends to identify opportunities for process improvement, submit DCRs, and provide targeted coaching recommendations.
•Enter and reconcile retail approvals and recommended denials (RADs) from NCH in MHK, performing root-cause analysis to address disparities between NCH and CPS UM.
•Conduct Quality Analysis reviews to ensure accuracy, compliance, and operational integrity across prior authorization processes.
•Develop and facilitate training sessions and presentations for new and existing team members on system navigation, workflows, and best practices.
•Create and present improvement process summaries and quality review reports to leadership, driving team development and operational consistency.
•Ensure full compliance with federal, state, and local regulatory guidelines governing pharmacy and prior authorization operations.
•Build and maintain strong collaborative relationships with internal departments, external partners, and providers to promote effective communication and service excellence.

• Track and triage coverage determination requests submitted from providers and determine if a pharmacist review is required
• Obtain verbal authorizations and request detailed clinical information from prescribers
• Approve coverage determination requests based on defined criteria
• Enter and document coverage determination request decision into the PBM system and notify providers and/or members. Respond to client inquiries regarding authorization approvals and PBM on-line applications. Refer coverage determination requests for specialty drugs to delegated vendor or client for processing. Contact providers for additional information to facilitate coverage determination reviews. Notify physicians, providers, and members of coverage determination request decisions

• Track and triage coverage determination requests submitted from providers and determine if a pharmacist review is required
• Obtain verbal authorizations and request detailed clinical information from prescribers
• Approve coverage determination requests based on defined criteria
• Enter and document coverage determination request decision into the PBM system and notify providers and/or members. Respond to client inquiries regarding authorization approvals and PBM on-line applications. Refer coverage determination requests for specialty drugs to delegated vendor or client for processing. Contact providers for additional information to facilitate coverage determination reviews. Notify physicians, providers, and members of coverage determination request decisions

• Provide excellent customer service is part of Advent Health service standards
• Dispense machines (pixes), fill med carts for each floor, deliver medications to inpatients and outpatient’s floors throughout the Hospital, and count out the correct number of capsules or tablets in the correct orders.
• Train intern Pharmacist and Pharmacy Technicians
• Establish an excellent communication with Physicians, Nurses and Pharmacist for an outstanding patient service

• Provided excellent customer service is part of Davita Rx Core Values to engage with patients on pleasant conversations and assist with their medications
• Handled inbound and outbound telephone calls with positive attitude toward patient, Physician Offices and Dialysis Facilities for new prescriptions, renewals and clarifications with the ability to handle a variety of situations
• Input information and researched prescription orders through SXC on Rx Express System and Rx Connect utilization to create New Rx or Renewals, Patient facility changes among other functions
• Followed guidelines of job demands, handled patient information, integrity and respect for patient confidentiality are crucial

• Provided excellent customer service is part of Davita Rx Core Values to engage with patients on pleasant conversations and assist with their medications
• Handled inbound and outbound telephone calls with positive attitude toward patient, Physician Offices and Dialysis Facilities for new prescriptions, renewals and clarifications with the ability to handle a variety of situations
• Input information and researched prescription orders through SXC on Rx Express System and Rx Connect utilization to create New Rx or Renewals, Patient facility changes among other functions
• Followed guidelines of job demands, handled patient information, integrity and respect for patient confidentiality are crucial

• Made decisions regarding the most appropriate course of action based on plan requirements, Walgreen policies and procedures, and other appropriate considerations
• Made telephone calls to insurers and others to obtain information, gain override approval or otherwise resolve the TPRs
• Handled inbound and outbound telephone calls with customers and insurance companies as needed, including transferring calls to the pharmacist on duty with the ability to handle a variety of situations