Laura Ocasio
Senior PBM Analyst
Commerce,US
Summary
Senior PBM Analyst with over 12 years of experience specializing within the Pharmacy Benefit Management healthcare industry, looking to utilize educational and professional experiences in a challenging position that will allow for continued personal and professional growth.
Overview
16
16
years of professional experience
1
1
year of post-secondary education
2
2
Certifications
2
2
Languages
Work History
Lead Pharmacy Operations Analyst
Blue Cross & Blue Shield of South Carolina
05.2023 - 06.2025
- Collaborated with technology, account management, benefit administration, compliance officers, and other internal stakeholders to ensure that eligibility and accumulator functions are implemented and operating in accordance with requirements.
- Oversaw all downstream vendor feeds (i.e., ID card fulfillment), third-party integrations (i.e., health plans, TPAs), and ensured all deliverables were met timely and troubleshot issues.
- Reviewed the benefit design document, developed and executed test scenarios to ensure the accuracy of the benefit setup both at the initial setup, and conducted ongoing monitoring and regression testing, as well as corrected all identified defects.
- Investigated and troubleshooted inquiries regarding issues related to claims adjudication, accumulators, and eligibility.
- Developed and supported attributes within claim transactions contracted with State governments with applied specific regulatory requirements to support their programs.
- Facilitated and moderated gap analysis and requirements gathering sessions for as-is and to-be stages of product development and accountable for compliance with state compliance.
- Worked with the team to identify, analyze, quantify, and mitigate risks.
- Educated staff on the organizational mission and goals to help employees achieve success.
- Worked with the project management office to utilize and enhance tools that support the requirements, development, and testing processes.
- Input from key stakeholders, prioritize business needs of the product and incorporate the criteria to develop the product’s functional releases.
- Generated reports detailing findings and recommendations.
- Implemented processes and procedures to streamline operations.
- Managed multiple projects simultaneously, delivering results within tight deadlines while maintaining high-quality standards.
- Strengthened communication between departments, facilitating a seamless flow of information for faster decision-making processes.
- Developed a procedure document to direct internal employees on pharmacy communications, aiding with pharmacy-related inquiries/issues, POC, as well as escalated issues.
- Developed workstream lead directory for POC.
- Created a tracking document for business functional testing, joint integration testing, and model office for both pre- and post-implementation phases.
- Reviewed, edited, and delivered internal pharmacy operations policy, as well as verified policies were in accordance with the SC DHHS (South Carolina Department of Health and Human Services).
- Developed an internal Preferred Drug List validation, ensuring PBM weekly coding was in accordance with state Medicaid direction.
- Provided internal employees with user access information to gain appropriate access to required external PBM platforms.
- Discussed with the external PBM all necessary, required information for the completion of the ISR, including the identified issue date, root cause, warranty process, as well as the final review before providing approval.
- Created a document detailing instructions on the validation of prescribers for OIG (federal and state lists) against the prescriber roster file.
- Reviewed state Medicaid member letters to ensure all state requirements are met, including reading statistics.
- Worked with both external PBM partners and the internal financial department to ensure that appropriate financial distribution of funds was delivered to all Medicaid-enrolled pharmacies on a quarterly basis.
- Addressed the State of Emergency (SOE) declared by the South Carolina governor. This included submitting client request form to the PBM to ensure all coding were appropriately in affect and met SOE requirements for pharmacy benefits in accordance with SCDHHS.
Senior Configuration & Operations Analyst
Abarca Health
12.2018 - 04.2023
- Reviewed, analyzed and submitted new formulary designs for internal approval as well as external client confirmation before live set-up within production environment.
- Performed end to end testing and validation of claims, formulary setups, platform configurations for contracted lines of business such as Medicare, Medicaid, Commercial and Exchange.
- Performed root cause analysis, corrective actions and provided remediation of any inaccuracies or misconfigurations discovered during quality check.
- Trained benefit configuration analysts and specialists. Provided leadership support to team members for escalations and complex configuration requests.
- Mentored and supported the benefit configuration team to drive innovation and determine best practices.
- Communicated to leadership project status, escalating issues , and presented changes to improve workflow efficiency.
- Gathered all required documentation to meet compliance within state Policy and Procedures in accordance with Medicare and Medicaid government programs as well as Commercial and Exchange line of business.
- Setup PBM benefits according to client’s specification while creating testing scenarios for client’s formularies and claims.
- Actively interacted with stakeholders and clients in all aspects of clinical and platform enhancements.
- Preformed daily phases of external client PBM building which included platform configuration, implementing enhancements and developments of platform software to achieve clients intended results.
- Performed all necessary implementation pre-Go-Live readiness and Post Go-live. Testing of user system acceptance while monitoring development and maintaining project management support.
- Advised external clients on regulations and adherence for Medicare and Medicaid government programs for requested configurations and requirements.
- Developed and updated tracking spreadsheets using sharepoint drive.
- Designed plans to improve operations and suggested changes to systems for overall organization.
Senior Business Analyst
Anthem
06.2018 - 12.2018
- Supported leadership team with reporting, analysis, and business presentations to inform divisional strategies.
- Created new analytical systems to boost vital business metrics visibility.
- Recruited new members for business analysis team to support division growth and create strong and productive department, replacing underperforming staff.
- Managed team performance by implementing measurable metrics to track delivery of supporting requirement artifacts.
- Translated high level business requirements into functional and non-functional requirement as per client’s specifications.
- Documented and recorded analysis findings into strategic data reports.
- Interfaced directly with senior business stakeholders and users.
Benefit Coding Consultant
CVS Health
10.2017 - 05.2018
- Responsible for coding PBM plan designs within adjudication support system.
- Developed coding strategies, designing complex coding solutions, driving automation, and providing tactical and strategic direction for coding functions.
- Validated, configured, maintained, implemented, and communicated benefit plan design additions and changes.
- Completed functional testing and technical development utilizing SQL and Salesforce software.
- Built and maintained communication with clients, testing centers, benefit coding teams and account management teams to expedite and maintain workflow.
- Developed and maintained relationships with project stakeholders to obtain project objectives while working in a matrix project environment.
Senior Product Implementation Consultant
Carefusion
01.2016 - 08.2017
- Organized project implementation resources and leveraged expertise to assist organizational rollout.
- Evaluated and defined internal and customer needs, implementing processes to address requirements.
- Documented specialized data and requirements to address business demands.
- Cultivated project timelines, documentation, processes and updates to develop and manage tactical plans.
- Performed and supervised required troubleshooting tasks to insure successful configuration.
Pharmacy Operations Analyst
Blue Cross Blue Shield
02.2014 - 12.2015
- Supported supervisor and associated team members to maintain system functionality.
- Performed validation and testing of models to promote adequacy and reformulate models as necessary.
- Identified and analyzed project risks and developed mitigation strategies.
- Engaged with internal departments and client account executives on strategies for adapting changes affecting corporate products and members attached to healthcare benefits.
- Efficiently gathered requirements to facilitate validation.
Pharmacy Benefits Analyst
AbbVie
04.2009 - 11.2013
- Investigated insurance benefits for specialty medications Humira and Lupron.
- Communicated with patients and physicians regarding insurance benefits and alternative financial options.
- Provided insurance benefit verifications for commercial, Medicare and Medicaid insurance plans.
- Forwarded specialty Medications to correct in-network specialty Pharmacies.
- Initiated prior authorizations and filed appeals to obtain insurance coverage of medication.
- Verified necessary medical criteria and diagnosis codes with Physicians and nurses to ensure pharmacy claims processed appropriately.
- Communicated with facilities on day-to-day basis to ensure that all medications arrive on schedule.
- Pursued Physicians signature approvals and correct lab analysis to submit to insurance company for medication approval.
Education
Pharmacy
Pharmacy Technical Program
Chicago, IL 07.2008 - 04.2009
Skills
System integration
Cross-functional teamwork
Microsoft SharePoint
Root Cause Analysis
Microsoft Word
Darwin system
Data analysis
Microsoft Access
Process updates
SQL, Rxclaims (AS400), SharePoint, Salesforce Certified, BestRX, Excel, Power Point, RXconnect, Specialty RX, Citrix, ES Medstation Pyxis, Macro Development, Centricity, Epic, Medispan, Darwin, GXcapture, COS Client Online Service tool
Configuration management
Database configuration
Systems configuration
Network configuration
System installation and configuration
Regulatory compliance reporting
Platform Trouble Shooting
Cross-Reference Validation
Organization and Time Management
Certification
Certified Pharmacy Technician, CPhT PTCB
Timeline
Lead Pharmacy Operations Analyst
Blue Cross & Blue Shield of South Carolina
05.2023 - 06.2025
Senior Configuration & Operations Analyst
Abarca Health
12.2018 - 04.2023
Senior Business Analyst
Anthem
06.2018 - 12.2018
Benefit Coding Consultant
CVS Health
10.2017 - 05.2018
Senior Product Implementation Consultant
Carefusion
01.2016 - 08.2017
Pharmacy Operations Analyst
Blue Cross Blue Shield
02.2014 - 12.2015
Certified Pharmacy Technician, CPhT PTCB
06-2011
Pharmacy Benefits Analyst
AbbVie
04.2009 - 11.2013
IDFPR Pharmacy Technician License
02-2009
Pharmacy
Pharmacy Technical Program
07.2008 - 04.2009
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