Certified Pharmacy Technician II/Claims Analyst II
Open To Work
MONIQUE MOORE-BROWN
Express Scripts
Tempe,AZ
Work Preference
Job Search Status:
Open to work
Desired Job Title
Claims AnalystClaims AdjusterPharmacy Benefit AssistantClaims Resolution SpecialistMedical Biller and Coder
Work Type
Full TimePart TimeContract Work
Location Preference
Remote
Analytical and detail driven healthcare operations professional with extensive experience in claims management, pharmacy operations, utilization review support, and patient care services across PBM, managed care, and retail pharmacy environments. Proven ability to resolve complex issues, interpret benefit structures, and collaborate with cross functional teams to improve accuracy, compliance, and member satisfaction. Skilled in analyzing medical and pharmacy claims, coordinating with providers and insurance representatives, and maintaining meticulous documentation aligned with regulatory standards. Recognized for effective communication, relationship building, and the ability to manage high volume workloads while ensuring quality and operational efficiency.
12
Years of experience
6
Certification
Work History
Patient Care Technician
5 Years 11 Months
Express Scripts - Tempe, AZ | 09.2020 - 08.2026
- Address issues, raised in Pull department. Perform tasks associated with Pull Rx, involving pulling, copying, faxing, and processing. Enter data, transcribe notes from customer support interactions, and manage overall member communications. Navigate through number of different systems. Assist patients in better understanding pharmacy benefits. Investigate current as well as previous prescription orders.
- Key Contributions:
- Prescription Processing: Accurately read, interpreted, and entered new and refill prescriptions into computer systems, including calculating doses, and confirming directions.
- Patient Communication: Answers inbound phone calls, helps enroll new patients, answers non-clinical questions, and resolves medication access or delivery issues.
- Insurance and Billing: Investigates insurance coverage, processes benefit verifications, and manages payment or reimbursement requirements.
- Care Coordination: Routes unclear or incomplete prescriptions to prescribers for clarification and works with clinical teams to support patient treatment plans.
- Administrative Support: Maintains patient profiles, handles records, and escalates complex medication or health issues to a licensed pharmacist. Returned calls from members and providers and placed calls to providers and members for follow-up and advice on issues such prior authorization, appeals, and DOD accounts.
- Documented patient information and care activities in electronic health record.
- Supported needs of 60+ residents under long-term care.
Claims Analyst
3 Years 7 Months
Centene Corporation - Tempe, AZ | 09.2016 - 04.2020
- Applied policy and provider contract rules to evaluate payable claim and claim require further information. Conducted research and analytics in support of area of business dealing with coordination of benefits (COB). Operated on variety of pended ss, which contain special pricing with supervisors and Tls. Elucidated health insurance coverage for benefits coordination to process claims and maintain records, files, and documents. Managed flow of requests for coverage determination from providers and prioritized that need further examination by pharmacist. Upheld accountability for claims processing for physician and hospital services, COB, special pricing, refunds, and changes on resubmitted claims. Ratified coverage determination requests using stated criteria. Oversaw client inquiries regarding authorization approvals and PBM on-line applications. Forwarded coverage determination requests for specialty drugs to delegated vendor and client for processing. Communicated decisions on coverage determination requests to doctors, hospitals, and patients.
- Key Contributions:
- Evaluated payable claims, identified those requiring additional information, and applied special pricing rules.
- Managed coverage determination workflows, prioritizing cases requiring pharmacist review.
- Processed claims for physician and hospital services, COB, refunds, and resubmissions.
- Communicated coverage decisions to providers, hospitals, and members with clarity and accuracy.
- Forwarded specialty drug coverage requests to delegated vendors and monitored resolution.
- Supported development of new post payment recovery methodologies for improperly coordinated pharmacy claims.
- Utilized Amisys to determine payment and rejection codes, ensuring adherence to departmental standards
- Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
- Maintained claims data in Prism and Pega systems.
Insurance Specialist
5 Months
REMX Ltd. - Phoenix, AZ | 11.2015 - 04.2016
- Gained experience in auditing, reviewing, and validating the accuracy of claims data and accuracy of claims payment preferred. Tasked with processing re-verification claims, calling existing clients' insurance providers, entering necessary data for processing claims, and obtaining previous authorizations. Applied published healthcare guidelines, such as D.0 regulations and coding guidelines to claims data.
- Applied D.0 regulations, CPT 4, ICD 9/10, HCPCS, ASA, and UB92 coding guidelines to ensure accurate claims processing.
- Conducted outbound calls to insurance companies to verify coverage and authorization requirements.
- Entered detailed claims information for ENTYVIO and other specialty medications.
- Ensured claims documentation met regulatory and payer standards.
- Tracked pending authorizations to resolve discrepancies and avoid revenue loss.
- Maintained confidentiality of patient finances, records, and health statuses.
- Negotiated with insurance underwriters to obtain better coverage and improved rates for clients.
- Identified potential risks in client businesses and recommended appropriate insurance coverage.
- Analyzed risk factors to recommend appropriate coverage levels.
- Determined financial needs by assessing existing coverage and aligning new products and services with long-term goals.
- Conducted research and identified market trends to develop better strategies for sales.
- Utilized CRM software to manage client relationships.
- Prepared and reviewed insurance applications to verify compliance with regulations.
- Cross-sold insurance products to existing clients to reach sales targets.
- Built relationships with clients using active listening and issue resolution to provide excellent service.
- Communicated effectively with members of operations, finance, and clinical departments.
- Followed up on denials, late payments, extensions and other special circumstances.
- Processed eligibility and benefits verification and authorization requests.
Certified Pharmacy Technician
1 Year 2 Months
QOL Meds-New Orleans - Phoenix, AZ | 06.2014 - 08.2015
- Supported with preparation of prescriptions, including entering patient information (demographics, drug allergies and pharmaceutical history) and prescription orders into computers for processing. Greeted with customers, maintained drugstore clean, and answered phone politely. Provided support to pharmacists in filling prescriptions by pulling stock, counting, restocking, packaging, and labeling and pricing prescriptions, bubble packing, mail order, balancing cash drawers and sending receipts to corporate.
- Key Contributions:
- Entered patient demographics, allergy information, and prescription orders with high accuracy.
- Prepared prescriptions by pulling stock, counting, packaging, labeling, and pricing medications.
- Manage inventory through ordering, receiving, rotating, and storing pharmaceutical products.
- Assisted with bubble packing, mail order processing, and cash drawer balancing.
- Restocked pharmacy shelves with current merchandise to drive consistent peripheral sales.
- Coordinated verification and filling of more than 40 daily prescriptions in high-volume Retail and Mail Order pharmacy environment.
- Communicated with prescribers to verify medication dosages, refill authorizations, and patient information.
- Solved customer problems in-person or over telephone by providing assistance with placing orders, navigating systems, and locating items.
- Stocked, labeled, and inventoried medication to keep accurate records.
- Maintained proper drug storage procedures, registries, and records for controlled drugs.
- Completed paperwork, entering prescription and insurance or billing information into patient profiles.
- Collected co-payments or full payments from customers.
- Calculated dosage, filled prescriptions, and prepared prescription labels with absolute accuracy.
- Maintained drug inventory levels by ordering necessary medications and supplies.
- Counted and labeled prescriptions with correct item and quantity.
- Communicated directly with doctors offices via telephone, fax and email.
Education
Pharmacy Technician
Remington College
AAS degree - Computer Electronics
City Colleges of Chicago
Skills
Claims Investigation | Management Support & Reporting | Customer Service | Patient Satisfaction | Strong Relationship Building | Risk Management Support | Quality Assurance | Cross-functional Collaboration | Complaint Resolution
Certification
- Certified Pharmacy Technician Arizona State Board of Pharmacy 01/15/015- 10/30/2027
- PTCB - Pharmacy Technician Certification Board 04/10/2012-09/30/2028
- Medication Therapy Management, 10/21/201,7National Certificate Training Program for Pharmacy Technicians
- AAPC Insurance Specifics Certificate, 09/11/2025
- NPTA's ACPE Accredited Pharmacy Technician Regulatory Compliance Certificate, 10/04/2024
- Louisiana Board of Pharmacy Technician, 04/10/2012-06/30/2027
Timeline
Patient Care Technician
Express Scripts
09.2020 - 08.2026Read more
Claims Analyst
Centene Corporation
09.2016 - 04.2020Read more
Insurance Specialist
REMX Ltd.
11.2015 - 04.2016Read more
Certified Pharmacy Technician
QOL Meds-New Orleans
06.2014 - 08.2015Read more
Remington College - , Pharmacy Technician
Read more
City Colleges of Chicago - AAS degree, Computer Electronics
Read more