Martha Garcia
Molina Healthcare of Florida
Miami,FL
1
Language
1
Certification
27
years of professional experience
Healthcare operations and pharmacy services professional with 20+ years of experience in managed care, health insurance operations, pharmacy benefit administration, reimbursement, and clinical support services. Extensive experience interpreting pharmacy benefit requirements, coordinating prior authorization processes, supporting regulatory compliance initiatives, and collaborating with cross-functional teams to implement operational changes. Skilled in analyzing claims data, developing dashboards and performance reports, identifying process improvement opportunities, and translating complex pharmacy and coverage requirements into actionable operational processes. Experienced in working with Government Contracts, Clinical Pharmacy, Case Management, and Communications teams to support regulatory alignment, quality improvement, and operational effectiveness. Proficient in QNXT, Rx Claim, Salesforce, Tableau, Power BI, and Microsoft Office.
Work History
Clinical Registered Pharmacy Technician / Account Specialist – Pharmacy Services
5 Years 10 Months- Analyze pharmacy claims, rejected prescriptions, prior authorization trends, and medication adherence data to identify operational issues and opportunities for improvement.
- Communicate pharmacy coverage requirements, authorization determinations, and operational updates to internal and external stakeholders.
- Run Member Lock-in report using Rx Navigator and analyzing data to provide recommendations for member pharmacy Lock-in following state criteria and report to the pharmacist.
- Interpret pharmacy benefit requirements, formulary guidelines, and prior authorization criteria, communicating policy interpretation to providers, pharmacies, and internal stakeholders.
- Manage member grievances and Agency for Health Care Administration (AHCA) complaints, ensuring accurate documentation, timely resolution, and adherence to applicable regulatory requirements.
- Identified and escalated member eligibility and payment-related discrepancies to Payment Integrity and Eligibility teams, facilitating research, issue resolution, and accurate application of health plan coverage requirements.
- Coordinate with Government Contracts and Clinical Pharmacy teams to manage quarterly Clinical Criteria reviews, submitting proposed updates for review and approval to ensure alignment with government contract requirements.
- Collaborate with the Communications team to coordinate publication of approved Clinical Criteria updates on the Molina provider website, supporting accurate communication and implementation of coverage requirements.
- Develop and maintain dashboards and reports to monitor key performance indicators, call metrics, pharmacy utilization trends, and operational performance.
- Prepare and communicate analytical findings and actionable insights through reports, including SAPO reporting, Hydroxyurea rejected claims analysis, and medication adherence tracking.
- Collaborate with pharmacists and Case Management teams to evaluate pharmacy-related concerns and resolve member access barriers.
- Coordinate pharmacy overrides and claims resolution with pharmacies and internal teams to address adjudication issues and facilitate appropriate medication access.
- Maintain accurate documentation of operational activities, case resolutions, and program outcomes to support compliance, reporting, and quality improvement.
- Participate in cross-functional initiatives and special projects focused on workflow optimization, operational efficiency, and improved service delivery.
Clinical Pharmacy Technician
3 Years 1 Month- Reviewed and processed medication prior authorization requests submitted by prescribers, applying pharmacist-approved clinical criteria and established pharmacy benefit requirements.
- Interpreted authorization criteria and communicated approval and denial determinations to providers, pharmacists, and care management teams.
- Researched and resolved complex pharmacy inquiries, authorization discrepancies, and member or provider grievances.
- Coordinated with pharmacies to process pharmacist-authorized overrides, resolve claims adjudication issues, and facilitate medication access.
- Documented authorization determinations, case research, and resolution activities within pharmacy management systems.
- Communicated formulary requirements, pharmacy benefit coverage, prior authorization criteria, and therapeutic alternatives to physicians and healthcare professionals.
Registered Pharmacy Technician / Exceptions Coordinator
10 Years 9 Months- Coordinated pharmacy exception processes, prior authorization activities, and prescription-related inquiries to support continuity of medication therapy.
- Researched, processed, and documented prior authorization determinations and communicated authorization expiration information to physician offices.
- Verified prescription accuracy and compliance with applicable federal and state pharmacy regulations.
- Coordinated with physician offices to obtain prescription clarifications, updated orders, and required documentation.
- Supported specialty pharmacy operations involving growth hormones, chemotherapy, infertility, and rheumatoid arthritis medications.
- Collaborated with Case Management teams to identify prescription-related barriers and coordinate solutions for medication access.
- Assisted intake and customer service departments with prescription processing, referral coordination, and resolution of pharmacy-related inquiries.
Intake Coordinator / Reimbursement Specialist
4 Years- Coordinated patient referrals, intake processes, insurance verification, and prior authorization requirements for infusion and specialty pharmacy services.
- Reviewed insurance benefits and identified coverage requirements for Medicare, Medicaid, HMOs, PPOs, and commercial insurance plans.
- Managed medical claims submission and reimbursement activities for infusion services, chemotherapy, TPN, enteral nutrition, home health care, and durable medical equipment.
- Reviewed ICD-9 and CPT coding accuracy to support appropriate claims submission and reimbursement.
- Coordinated with insurance companies and healthcare providers to resolve reimbursement and authorization issues.
Billing Analyst
4 Months- Managed medical claims billing and insurance eligibility verification.
- Reviewed ICD-9 and CPT coding accuracy before claims submission.
- Investigated payment discrepancies and coordinated resolution with customers and internal departments.
Billing and Collections Specialist
2 Years 10 Months- Managed medical equipment billing, claims submission, and insurance reimbursement activities.
- Prepared and submitted fee-for-service claims to insurance payors.
- Monitored account activity, investigated outstanding balances, and coordinated claim resubmissions.
- Collaborated with Customer Service and Intake departments to resolve billing issues and coordinate patient referrals.
Education
Associate Degree - Health Services Administration
High School Diploma
Skills
Healthcare Operations & Managed Care
Pharmacy Benefit Administration
Regulatory Compliance & Policy Interpretation
Clinical Criteria Coordination
Government Contract Requirements
Business Process Improvement
Operational Analysis & Reporting
Claims Analysis
Quality Improvement Initiatives
Performance Metrics & KPI Reporting
Prior Authorization & Formulary Management
Grievance and Complaint Resolution
Process Documentation
Systems & Applications: Microsoft Excel
Word
PowerPoint
Outlook
Publisher
Tableau
Power BI
QNXT
Salesforce
Rx Claim
Medisoft
CPR+.
Certification
Credential: Registered Pharmacy Technician – Florida, RPT 4508.
5. Technical skills
Languages: English and Spanish (fluent).
Timeline
Clinical Registered Pharmacy Technician / Account Specialist – Pharmacy Services
Molina Healthcare of Florida
01.2021 - CurrentRead More
Clinical Pharmacy Technician
Magellan Complete Care – Magellan Health Services
12.2017 - 01.2021Read More
Registered Pharmacy Technician / Exceptions Coordinator
Magellan Rx Pharmacy – Magellan Health Services
03.2007 - 12.2017Read More
Intake Coordinator / Reimbursement Specialist
Infusion Technologies, Inc. / Atlantic Pharmaceuticals, Inc.
03.2003 - 03.2007Read More
Billing Analyst
Cardiovascular Diagnostic Image, Inc.
11.2002 - 03.2003Read More
Billing and Collections Specialist
All-Med Services of Florida, Inc.
12.1999 - 10.2002Read More
Hialeah High School
High School Diploma
Read More
National School of Technology
Associate Degree from Health Services Administration
Read More