Kimberly Heflin

Work History

Clinical Prior Authorization Pharmacist

Gainwell Technologies

Dublin, OH

04.2023 - 11.2023

Clinical evaluation of medication therapy.
Peer to Peer discussions with medical providers to discuss prior authorization reviews.
Ensured compliance with prior authorization criteria and guidelines established by insurance companies.
Provided timely responses to requests for prior authorizations from medical professions using the PDL Criteria.
Communicated with medical providers regarding updates on status of pending authorizations.
Monitored reports detailing utilization of medications requiring prior authorization approval.
Investigated discrepancies between submitted claims and approved and denied authorizations.
Quality Improvement: Contributes to program improvements by using continuous quality improvement processes, by being proactive in identifying improvement processes and opportunities by contributing ongoing consultation and collaboration with product leaders.
Operations: Contributes to the success of the Clinical Call Centers and Prior Authorization department by assisting with the implementation and management of both written and verbal communications to members and physicians.
Available for consultation on pharmacy-related questions and issues for others within the organization.
Researched alternative medications when requested by prescribers or patients due to denial of an authorization request.
Participated in daily meetings with team members to discuss new initiatives and challenges encountered during the month.
Advised physicians on appropriate use of medication therapies based on clinical evidence and cost effectiveness.
Collaborated with other departments within the organization to resolve complex issues pertaining to reimbursement policies.
Assisted in resolving customer service issues related to the processing of prior authorizations.
Reviewed patient's prescription for accuracy and completeness, verifying that all information is correct.

Staff Pharmacist

Allen Pharmacy & Wellness

Allen, Texas

02.2023 - 05.2023

Accurately filled and verified prescriptions for hospice and long term care facility patients.
Ordered, labeled, compounded and dispensed prescribed medications.
Provided medication counseling to patients on the proper use and potential side effects of their medications.
Compounded specialty medications to include ointments, troches, and capsules.
Reviewed prescriptions for accuracy and completeness prior to dispensing.
Performed administrative duties such as updating patient information or submitting insurance claims forms.
Interpreted prescription orders from physicians or other authorized prescribers to ensure accuracy of medication preparation and delivery.
Organized inventory control systems to maintain adequate stock levels for all products carried by the pharmacy.
Coordinated activities with other healthcare personnel involved in patient care management plans.
Verified third party reimbursement eligibility through automated systems.
Monitored medication inventory levels and kept detailed documentation in company software.
Communicated with member physicians to prevent harmful drug reactions, therapy duplications and allergic reactions.
Oversaw drug preparation and distribution activities to provide safe, efficient care for patients.
Mentored pharmacy technicians and trainees, providing insight and answering questions regarding company procedures and medical protocols.
Administered flu, pneumococcal, and Covid-19 immunizations to patients to prevent illness and promote well-being.

Prior Authorization Pharmacist

Optum, UnitedHealth Group

, TX

07.2022 - 11.2022

Verified prescription information against safety guidelines and insurance limitations to protect patient health and financial interests.
Analyzed prescribing trends to monitor compliance and prevent excessive usage.
Maintained confidential financial and patient information to reduce risk of data breaches.
Provided accurate information to all parties, including patients, insurance providers, healthcare staff and office personnel by using effective written and verbal communication skills.
Notified ordering providers of denied authorizations.
Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
Performed detailed medical reviews of prior authorization request, following established criteria and protocols.
Detected and reported therapeutic incompatibilities.
Used PCOMM and PAS to input claim, prior authorization and other important medical data into system.
Collaborated with internal departments to provide account status updates.
Adhered to regulatory guidelines for workplace safety and customer confidentiality.
Ensured compliance with prior authorization criteria and guidelines established by insurance companies.

Staff Pharmacist

CVS Pharmacy

Grapevine, TX

09.2021 - 07.2022

Oversaw drug preparation and distribution activities to provide safe, efficient care for patients.
Delivered pharmacological education to patients by responding to and answering questions and explaining medication side effects.
Checked prescriptions for appropriate dosage, drug interactions or allergies before dispensing medications.
Collaborated closely with healthcare professionals to monitor and assess quality and effectiveness of drugs or drug regimens.
Verified prescription information against safety guidelines and insurance limitations to protect patient health and financial interests.
Improved inventory management procedures to reduce overhead, backorders and overstock.
Oversaw and monitored dispensation of controlled substances according to regulatory requirements.
Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
Administered vaccines to immunize patients against communicable diseases.
Secured drugs against theft, loss or mismanagement by setting and enforcing effective procedures.

Operations Specialist 3

IQVIA

03.2021 - 06.2021

Created Adverse Event and Product Quality Complaint reports requiring concise data entry, writing narratives and generating case queries.
Maintained safety and emergency readiness among personnel by disseminating information on and monitoring compliance with regulatory and organizational policies.
Disseminated clear, accurate information to healthcare professionals and patients based on approved resources related to the use of client products.
Clarify, investigate and capture adverse event and product quality information.
Utilized computerized Resource and Patient Management System (RPMS) and Electronic Health Record (EHR) system.
Documented services and collected required data for evaluation.

Staff Pharmacist/Immunization/ COVID-19 Vaccinator

CVS Pharmacy

Plano, TX

08.2020 - 03.2021

Administered COVID-19, Influenza and Pneumonia vaccines and injections to assist customers with medical needs and prevention of communicable diseases.
Established clear and effective customer service policies to increase satisfaction and pharmacy loyalty.
Communicated with member physicians to prevent harmful drug reactions, therapy duplications and allergic reactions.
Advised patients on potential drug interactions and side effects, proper dose timing and medication storage.
Recommended over-the-counter medications for patients after assessing symptoms.
Checked medications for content, accuracy and completeness of all drug packaging and labeling.
Mentored pharmacy technicians and trainees, providing insight and answering questions regarding company procedures and medical protocols.
Prioritized and consistently accomplished customer satisfaction and loyalty by fostering relationships with patients.
Led and performed all aspects of pharmacy operations, delivering continuous quality products and services in alignment with physician orders and prescriptions.
Managed medication therapy, providing information and responding to questions.
Advised and consulted with patients on potential side effects, drug interactions, storage requirements, and directions for use.

Staff Pharmacist

Alliance Rx Walgreens Prime Specialty Pharmacy

Dallas, TX

04.2020 - 05.2020

Created new customer profiles and updated changes such as demographics, allergies and new medications in pharmacy computer systems.
Handled all delegated tasks, including transferring prescriptions and resolving third party rejections.
Teamed with peers, technicians and pharmacists to prioritize and complete orders.
Transmitted claims to insurance companies for payment and reconciled EOBs.
Maintained compliance with healthcare, industry and facility rules and regulations.
Communicated with member physicians to prevent harmful drug reactions, therapy duplications and allergic reactions.

Staff Pharmacist

Walgreens

Lewisville, Texas

08.2000 - 10.2019

Provided (MTM) Medication Therapy Management to patients using Outcomes and Mirixa.
Extended patient engagement with extra counseling and follow-up adherence calls.
Provided specialized services to help patients manage conditions such as diabetes, asthma, smoking cessation and high blood pressure.
Conducted blood pressure screenings and counseled patients on hypertension.
Saved patients money and increased pharmacy profit margins with therapeutically equivalent and more cost-effective generic drugs.
Precisely processed third party prescriptions and managed adjudication review.
Advised patients on potential drug interactions and side effects, proper dose timing and medication storage.
Improved drug inventory management procedures to reduce waste and eliminate backorders or overstock.
Discussed over-the-counter medication and equipment options to help patients deal with individual symptoms.
Administered vaccines to immunize patients against communicable diseases.
Conducted drug utilization reviews, drug interventions and therapy management.
Enforced adherence to state, federal, and organizational rules and regulations.
Appropriately resolved customer issues, complaints and questions.
Monitored dispensation of controlled substances, including C-II to C-V drugs through careful oversight and Good Faith Dispensing.
Directly supervised 5 pharmacy technicians, interns and support staff while on duty.
Processed up to 400 prescriptions on high volume days with 100% accuracy.
Increased staff's pharmaceutical knowledge through training.
Followed state and federal record keeping guidelines for legend drugs and controlled substances.
Effectively prioritized tasks and organized workflow to increase efficiency.

Summary

Overview

Work History

Clinical Prior Authorization Pharmacist

Staff Pharmacist

Prior Authorization Pharmacist

Staff Pharmacist

Operations Specialist 3

Staff Pharmacist/Immunization/ COVID-19 Vaccinator

Staff Pharmacist

Staff Pharmacist

Education

Doctor of Pharmacy -

Skills

Affiliations

Timeline

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