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MONIQUE H BROWN
Maricopa,AZ
Summary
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.
Overview
1
1
Language
1
1
Certification
12
12
years of professional experience
Work History
Patient Care Technician
Express Scripts
Tempe, AZ
09.2020 - 08.2026
- Addressed issues in Pull department by performing tasks associated with Pull Rx, including pulling, copying, faxing, and processing. Entered data, transcribed notes from customer support interactions, and managed overall member communications to assist patients in better understanding pharmacy benefits and investigated current and previous prescription orders.
- Described significant contributions to team projects and initiatives.
- 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.
- Investigated insurance coverage, processed benefit verifications, and managed payment and reimbursement requirements to ensure seamless patient access to medications.
- Care Coordination: Routes unclear or incomplete prescriptions to prescribers for clarification and works with clinical teams to support patient treatment plans.
- Maintained patient profiles, managed records, and escalated complex medication or health issues to a licensed pharmacist. Followed up with members and providers on prior authorization, appeals, and DOD accounts to ensure continuity of care.
- Documented patient information accurately in electronic health records to ensure comprehensive care. and care activities in electronic health record.
- Assisted in meeting the needs of over 60 residents in long-term care. of 60+ residents under long-term care.
Claims Analyst
Centene Corporation
Tempe, AZ
09.2016 - 04.2020
- Applied policy and provider contract rules to evaluate payable claim and claim requiring further information. Conducted research and analytics in support of area of business dealing with coordination of benefits (COB). Operated on a 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 requests for coverage determination from providers and prioritized cases for pharmacist examination. 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 and identified those needing additional information while applying special pricing rules to ensure accurate processing.
- Managed coverage determination workflows by prioritizing cases for pharmacist review, facilitating timely claim resolutions.
- Processed claims for physician and hospital services, including COB, refunds, and resubmissions, ensuring adherence to compliance standards.
- Communicated coverage decisions to providers, hospitals, and members, enhancing understanding and transparency in the claims process.
- Forwarded specialty drug coverage requests to delegated vendors and monitored resolution.
- Supported development of new post payment recovery methodologies for improperly coordinated pharmacy claims.
- Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
Insurance Specialist
REMX Ltd.
Phoenix, AZ
11.2015 - 04.2016
- Audited, reviewed, and validated claims data for accuracy, processed re-verification claims by contacting insurance providers, entering data, and obtaining previous authorizations, while applying healthcare guidelines such as D.0 regulations and coding standards.
- Gained experience in auditing, reviewing, and validating the accuracy of claims data and accuracy of claims payment preferred. Processed re-verification claims by 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.
- Verified coverage and authorization requirements through outbound calls to insurance companies, facilitating efficient claims processing.
- Monitored pending authorizations to resolve discrepancies.
- Negotiated with insurance underwriters to secure optimal coverage and rates for clients, enhancing their insurance solutions.
- 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.
- Prepared and reviewed insurance applications to verify compliance with regulations.
- Built relationships with clients using active listening and issue resolution to provide excellent service.
- Communicated effectively with members of operations, finance, and clinical departments.
- Entered detailed claims information for ENTYVIO and other specialty medications.
Certified Pharmacy Technician
QOL Meds-New Orleans
Phoenix, AZ
06.2014 - 08.2015
- Key Contributions:
- Coordinated verification and filling of more than 40 daily prescriptions in high-volume Retail and Mail Order pharmacy environment.
- Entered patient demographics, allergy information, and prescription orders with high accuracy.
- Prepared prescriptions by pulling stock, counting, packaging, labeling, and pricing medications.
- Calculated dosage, filled prescriptions, and prepared prescription labels with absolute accuracy.
- Managed inventory through ordering, receiving, rotating, and storing pharmaceutical products.
- Verified medication dosages, refill authorizations, and patient information through effective communication with prescribers.
- Resolved customer issues by assisting with order placements and providing guidance on product availability in-person and over the telephone.
- Ensured compliance with drug storage procedures, maintaining registries and records for controlled drugs.
- Stocked pharmacy shelves with medications and supplies to ensure availability for customers., 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.
- Counted and labeled prescriptions with correct item and quantity.
Education
Pharmacy Technician - Pharmacy Technician
Remington College
Baton Rouge, LA09-2011
Associate of Science - Computer Electronics
City Colleges of Chicago Olive-Harvey
Chicago, ILSkills
- Patient safety compliance
- Strong attention to detail
- Data security
- Cross-functional team support
- Problem-solving expertise
- Customer service excellence
- Accurate patient documentation
- Patient education
- HIPAA compliance
Work Preference
Job Search Status
Open to workDesired Job Title
Claims AnalystClaims AdjusterPharmacy Benefit AssistantClaims Resolution SpecialistMedical Biller and CoderWork Type
Full TimePart TimeContract WorkLocation Preference
RemoteAccomplishments
Achieved Centene Excellence Award for Consistent and Unwavering Excellence During The 4th Quarter of 2019
Achieved Centene Excellence Award for Consistent and Unwavering Excellence During The 4th Quarter of 2018
Achieved Centene Excellence Award for Consistent and Unwavering Excellence During The 1st Quarter of 2019
Affiliations
NABP
AAPC
NPTA
PTCB
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
Languages
English
Full Professional
Interests
- Road Trips
- Train Travel
- Historical Exploration
- Exploring famous landmarks, historical sites, and cultural attractions in a new destination
- Dancing
- Swimming
- Passionate about balancing physical health with mental and emotional wellness
- I participate in low-impact exercises to strengthen core muscles
- Coding
- Horseback Riding
Timeline
Patient Care Technician
Express Scripts
09.2020 - 08.2026
Claims Analyst
Centene Corporation
09.2016 - 04.2020
Insurance Specialist
REMX Ltd.
11.2015 - 04.2016
Certified Pharmacy Technician
QOL Meds-New Orleans
06.2014 - 08.2015
Pharmacy Technician - Pharmacy Technician
Remington College
Associate of Science - Computer Electronics
City Colleges of Chicago Olive-Harvey
Awards
Achieved Centene Excellence Award for Consistent and Unwavering Excellence During The 4th Quarter of 2019
Achieved Centene Excellence Award for Consistent and Unwavering Excellence During The 1st Quarter of 2019
Achieved Centene Excellence Award for Consistent and Unwavering Excellence During The 4th Quarter of 2018
Achieve BSN
I intend to achieve my BSN in order to continue the care for patients quality of life and to continue advocating for domestic abuse of women and children.