Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Martin Quistian

Summary

Martin is a state of Florida licensed pharmacy technician and seasoned healthcare professional with eleven years of experience and strong leadership in claims, business analysis, pharmacy operations, patient care and customer service. Expert in working in fast-paced, high-volume settings while delivering high-quality care that empowers patients to live a healthier life. Seeking to leverage background and success to take the next career step as a Healthcare Manager.

Overview

11
11
years of professional experience
1
1
Certification

Work History

Claims Business Process Analyst Sr (UAT)

United Health Group
12.2023 - Current
  • Performed User Acceptance Testing (UAT) and Quality Assurance
  • Analyzed and decomposed business requirements to extract test requirements
  • Developed, implemented and executed effective test plans and test cases
  • Analyzed data, researched & troubleshot issues to define root cause and providing results
  • Logged and tracked defects to closure
  • Monitored, measured and communicated test results
  • Helped ensure new system requirements were tested thoroughly, accurately and delivered in a timely manner
  • Created and prepared UAT documentation, communication, and process workflow
  • Provided consistent and repeatable testing process for UAT
  • Worked closely with Project Team to identify risks early
  • Improved processes and reduced post implementation issues

Appeals Representative

United Health Group
04.2022 - 12.2023
  • Researched and resolved written/verbal complaints submitted by consumers and physicians/providers
  • Provided expertise or general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims
  • Conducted data entry and re-work; analyzed and identified trends and provided reports as necessary
  • Ensured complaints and grievances have been categorized correctly
  • Obtained additional documentation required for case review
  • Reviewed case to determine if review by clinician is required
  • Rendered decisions for non-clinical complaints using sound, fact-based decision making
  • Completed necessary documentation of final appeals or grievance determination using appropriate templates
  • Communicated appeal or grievance information to members or providers and internal/external parties within the required timeframes
  • Effectively interacted with other departments to obtain original claims processing details
  • Created correspondence that explained the claim resolution/outcome as well as next steps/actions for the member

Prior Authorization Specialist

United Health Group
10.2021 - 02.2022
  • Contacted insurance payers to obtain prior authorization on a timely basis, prior to a patient's treatment. Includes gathering additional clinical information as necessary to obtain prior authorization
  • Worked with doctors and nurses to understand patient treatment orders/plans, diagnosis, medical history to obtain prior authorization
  • Ensured prior authorization requests have been categorized, initiated and submitted correctly including receiving, analyzing, evaluating, and tracking prior authorization/clinical documents.
  • Researched and resolved verbal complaints by members and physicians/providers using concrete, fact detailed decision making
  • Communicated prior authorization and appeal status information to members, providers and internal/external parties within the required timeframes
  • Updated prior authorizations, trouble shooting, correcting errors as well as placing overrides in PAS system to ensure paid claim status by following company guidelines
  • Updated and maintained the accuracy of case processing for each member to ensure prior authorization requirements (such as job aids, policies, and procedures) are met for when inquiries are received
  • Contacted insurance payers to extend expired prior authorizations
  • Managed insurance changes and verify existing authorizations are valid
  • Understood insurance requirements for prior authorization
  • Understood payer processes to submit appropriate clinical documentation
  • Policy and procedure maintenance according to PA medication guidelines
  • (Contracted)

Registered Certified Pharmacy Technician

Walgreens
10.2017 - 10.2022
  • Used Walgreens prescription data entry procedures and guidelines, processed new patient registration by entering data into appropriate system
  • Handled patient prescription requests within HIPAA guidelines and entered refill orders for processing.
  • Troubleshot to obtain missing prescription information, and interpreted medical abbreviations (SIG codes)
  • Resolved intermediate to complex questions or issues that reflect substantial variety and detail.
  • Served as a resource for lower level technicians
  • Assisted with difficult customers and/or requiring in-depth knowledge.
  • Handled correspondence to patients and made outbound calls to patients and prescribers as needed
  • Served as the first escalation point for problem resolution. Anticipated client needs and proactively identifies solutions
  • Resolved Third Party Rejects by reviewing, gathering information, making corrections and resubmitting for processing according to individual plan requirements
  • Made telephone calls to insurers and others to obtain information, gain override approval or otherwise resolve the Third Party Rejects where applicable
  • Provided assistance to Pharmacists, both those in the facility and those at other locations
  • Monitored trends and notify pharmacists of recurring or high priority issues
  • Proactively looked for ways to improve current processes with enhancements and ideas
  • Checked medications for content, accuracy and completeness of all drug packaging and labeling to provide final verification of prescription. Checking for possible interactions
  • Merchandised related products to drive pharmacy department sales
  • Provided extraordinary customer care to patients

Registered Certified Pharmacy Technician PRN

Capital Regional Medical Center
06.2019 - 12.2021
  • Regularly stocked medications to Pyxis Machines
  • Delivered medications to nurses and patients on the floor when needed
  • Compounded IVs for the entire hospital, including chemotherapy, NICU dilutions/fluids, and narcotic drips
  • Received phone calls from nurses, doctors, and other healthcare professionals throughout the day, responding to requests promptly
  • Credited unused medications in billing and other secretarial/billing needs pertaining to the pharmacy

Certified Pharmacy Technician Data Entry PRN

PharMerica
08.2019 - 07.2021
  • Contacted insurance payers to obtain prior authorization on a timely basis, prior to a patient's treatment. Gathered additional clinical information as necessary to obtain prior authorization
  • Entered prescription orders into computer system for filling
  • Filled prescriptions according to quality standards, productivity guidelines and State Board of Pharmacy Regulations
  • Communicated with skilled nursing facilities to clarify orders
  • Sent incomplete, unclear or rejected prescription to appropriate nursing facility for resolution
  • Ensured that patient's allergies, therapies, and current medication were updated regularly in patient profile history

Registered Pharmacy Technician

CVS
05.2014 - 02.2017
  • Retrieved and processed prescription orders, counted, poured, measured and weighed medications
  • Maintained inventory management and storage, completed appropriate documentation, such as labels, log sheets and reports
  • Validated insurance coverage and communication with patients
  • Assisted pharmacist and communicated directly with patients over the telephone, scheduling medication deliveries, tracking lab data, billing, and prior authorization
  • Improved drug inventory management system to reduce waste and eliminate backorders
  • Exemplified excellent written and verbal customer service skills and advanced computer skills in order to interact with key partners and patients

Education

Bachelor of Science - Psychology/Pre-Pharmacy

Florida State University
Tallahassee, FL

Skills

  • Strong interpersonal, verbal, and written communications skills, with strong sense of personal initiative and accountability
  • Ability to multi-task, solid time management and organizational skills
  • Problem solving and analysis in clinical environment
  • Knowledge of ICD9, ICD10, CPT, HCPCS codes
  • Ability to collaborate effectively with multiple teams and employees through all levels
  • Hospital and physician claims knowledge, claim payments, claims adjudication, claims SOP adherence
  • Strong attention to detail, decision-making and planning skills
  • PACE facts, COSMOS, NICE, PAS, AS400, UNET and CPS claim processing and research experience
  • Proficiency with computer, Microsoft Suite and Windows PC applications, which includes the ability to navigate and learn new and complex computer system applications
  • Dedicated to help uncover issues, identify best practices, and help achieve exceptional results
  • Understand, maintain and apply HIPAA confidentiality and privacy guidelines
  • Ability to work effectively with sensitive and confidential material and emotionally charged matters
  • Accustomed to working in fast-paced technical and metrics - based environment
  • ICUE, Maestro, Scion, eviCore, naviHealth and iSET data analysis and research experience
  • Professional and positive commitment to service delivery
  • Experience with routing service forms through MACESS
  • Experience with UHC Medicare and Retirement, Community and State Medicaid Products
  • Active listener and critical thinking skills

Certification

  • Registered Pharmacy Technician, State of Florida
  • Basic Life Support (BLS) Certification
  • CPR Certification
  • Automated External Defibrillator (AED) Certification

Timeline

Claims Business Process Analyst Sr (UAT)

United Health Group
12.2023 - Current

Appeals Representative

United Health Group
04.2022 - 12.2023

Prior Authorization Specialist

United Health Group
10.2021 - 02.2022

Certified Pharmacy Technician Data Entry PRN

PharMerica
08.2019 - 07.2021

Registered Certified Pharmacy Technician PRN

Capital Regional Medical Center
06.2019 - 12.2021

Registered Certified Pharmacy Technician

Walgreens
10.2017 - 10.2022

Registered Pharmacy Technician

CVS
05.2014 - 02.2017

Bachelor of Science - Psychology/Pre-Pharmacy

Florida State University

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Martin Quistian