RACHEL RICH
Omaha,NE
Summary
Multi-talented Clinical Review Specialist with a quality-driven and disciplined approach to completing medication reviews for patients in Medicare Part D. Decisive leader, strategic planner and complex problem-solver with 6 years of experience with Prime, 23 years total pharmacy experience. Pursuing new professional challenges with this growth-oriented patient-care centered company as a Clinical Program Pharmacist.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Clinical Review Pharmacist Medicare Part D
Prime Therapeutics
2017.10 - Current
- Accurately completed reviews of medications for Medicare Part D patients according to plan rules and CMS guidance.
- Expert knowledge of all clinical programs for Medicare Part D including prior authorizations, formulary exceptions, drug utilization, hospice, case management, tier exceptions and paper claims. Experience with complicated programs including Part B vs Part D, oncology, hepatitis, biologic immunomodulators and hemophilia drugs.
- Proficient in use of Lotus, Clinical Review Engine, CORE, Single Point CORE builder, HighTouchRx platform, Jira, MSA Toolbox, CoverMyMeds and Criteria Builder, RxClaims, Word and Excel Programs. Completed initial training for ForUM.
- Effective use of RxClaims system to review prescription records, patient eligibility dates, pharmacy rejections and determine correct UM programs.
- Maintained excellent review quality despite high queue volumes and reduced technician outreach.
- Continuously meeting production goals for productivity and quality across multiple reviewing systems.
- Enthusiastically assumed administrative duties including answering pharmacist clinical/criteria questions, processing reopens, peer to peer discussions and closing and weekend pharmacist tasks.
- Maintained a positive attitude throughout challenges due to extreme growth in current department, including training challenges, process changes, and exponential team expansion.
- Contributed regularly to discussions related to process changes and improvements, and encouraged interdepartmental communications in this area to align processes between different lines of business.
- Volunteered for cross-training in Medicaid. Continuously provided support during times of increased volume in that department.
- Successfully completed CORE migration of Medicaid clinical criteria from LOTUS to CORE as part of a special project team lead by Tony Tran.
- Exceeded expectations covering colleague's maternity leave in HighTouch department, reaching difficult performance goals for 2 quarters for NE and KS clients. Presented and discussed savings opportunities with clients in regular meetings and addressed challenges that arose. Collaborated effectively with colleagues and providers to find savings for members and clients and completed outreach to secure savings.
- Gained skills in Single Point system and became proficient in building CORE criteria from UM documents.
- Effective communication. For criteria migration projects, this involved constant communication with UM, Operations and Criteria colleagues. Diligent pursuit of clear answers to prevent any future confusion with criteria that has been migrated to the new CORE system.
- Volunteered and completed training for FEP concierge Rph calls and assisted members that called in.
- Assisted with audits for new hire Rph cases and coaching related to this.
- Served as new hire point of contact in Omaha for pharmacists. Helped with new hire orientation and provided mentoring help for new hires in Omaha.
- Acted as move captain for my team and others when transitioning to a new building.
- Volunteered to work additional weekends, holidays, and overtime as business needs arose.
- Maintained Medicare Part D skills while working on criteria migration project and filling in for maternity leave in HighTouch department. Took the initiative to do this on my own as it was not required. Volunteered for overtime in Medicare Part D during this time period when needed.
- Continuously demonstrate flexibility by switching schedules and covering closing shifts and administrative duties for colleagues when needed.
- Completed continuing education courses to improve clinical knowledge in areas of immunotherapy, oncology, and hepatitis management.
- Active member of the safety team in the Omaha office when it was open. Carried a communications radio in office and assisted with emergency situations like seizures as they arose.
- Constantly encourage team engagement and participation in team discussions and volunteer events. Also organized multiple team volunteer events in the Omaha area.
- Passion for continuously learning new skills, collaborating with new colleagues, and expanding my professional knowledge base.
Interim Clinical Criteria Pharmacist
Prime Therapeutics
2021.06 - 2022.11
- Helped lead initial migration of Commercial and Medicare Part D criteria from CMM and CRE to CORE.
- Collaborated with UM, Clinical Operations,Criteria, and Regulatory colleagues to successfully complete initial transfer of criteria into CORE.
- Diligently pursued clear answers to prevent future confusion with criteria that has been migrated to the new CORE system. Clarified operational differences between new and old systems and pursued the clearest, most user-friendly solutions for future users.
- Continuously discussed CORE system enhancements and helped prioritize these through team discussions with operators and system builders.
- Drove innovation by reworking several clinical programs to present specific questions to prescribers at the online portal so they could provide appropriate information to lead to automatic approval.
- Identified several additional clinical programs that would be eligible for automatic review with minor updates to format and built examples of the specific criteria with updates to share with the migration team. Implemented several of these updates after interdepartmental discussions.
- Identified limitations of the new CORE system and conducted many interdepartmental meetings to discuss workarounds until system enhancements are available. Implemented and continuously communicated changes as they developed during migration with criteria and clinical operations teams.
Pharmacist
Walgreens Pharmacy
2009.07 - 2018.04
- Properly filled and dispensed prescriptions in a busy pharmacy environment, averaging 500+ prescriptions per day
- Checked prescriptions for appropriate dosage, drug interactions, allergies and contra-indications before dispensing medications
- Receptively answered customer questions about pediatric dosing, side effects, drug interactions, and much more
- Provided recommendations for over-the-counter products and helped locate desired items in the pharmacy and other areas of the retail store
- Built long-lasting patient relationships with 12+ years of service at the same location
- Saved patients money and increased pharmacy profit margins with therapeutically equivalent and more cost-effective generic drugs
- Directly supervised Pharmacy Technicians, interns and support staff while on duty
- Resolved scheduling issues and facilitated staff conflict resolution
- Effectively prioritized tasks and directed workflow to increase efficiency
- Properly instructed pharmacy students and residents on introductory and advanced pharmacy practice rotations
- Effectively resolved insurance rejections and assisted in completion of CMN forms and prior authorizations
- Communicated regularly with physicians, nurses, insurance companies and managed care organizations
- Provided recommendations to physicians about dosing, drug selection, monitoring, and drug interactions
- Compounded medications, including topical formulations, solutions and suspensions, troches, suppositories and capsules
- Troubleshot mechanical issues with Parata, Yuyama, and Scriptpro drug dispensing machines and other equipment
- Conducted blood pressure screenings and counseled patients on hypertension
- Provided health screenings including measurement of A1C levels, cholesterol profiles, body composition tests, etc
- Maintained CLIA waiver records and documentation and ran regular controls for all health screening tests
- Immunized patients with a variety of vaccines including influenza, Prevnar, Pneumovax, Zostavax, Tdap, MMR, Hepatitis A and B, Varivax, Menveo and Gardasil
- Completed specialized training and provided immunizations for travel clinics including vaccines for yellow fever, typhoid, rabies, and polio
- Specialized in providing medication therapy management to patients using Outcomes and Mirixa
- Served as Acting Pharmacy Manager when Pharmacist-in-Charge was on vacation
- Correctly completed pharmacy paperwork, including daily and weekly reports
- Maintained filing systems consistent with state and federal pharmacy laws.
- Improved patient outcomes by providing comprehensive medication therapy management and counseling.
- Enhanced pharmacy efficiency by implementing new workflow processes and inventory management systems.
Senior Pharmacy Technician and Pharmacist Intern
Walgreens Pharmacy
2000.10 - 2009.07
- Effectively resolved insurance rejections and other billing issues
- Assisted other pharmacy staff with drug inventory, purchasing, and receiving
- Regularly stocked shelves, rotated stock and checked for expired medications
- Performed technical processes required to dispense medications to patients
- Completed new and updated patient profiles, including lists of patient medications
- Prepacked bulk medicines, filled bottles with prescribed medications and affixed correct labels
- Cleaned equipment and work areas and sterilized glassware to maintain safe and sanitary conditions
- Efficiently operated cash register and handled cash, checks, and charge transactions
- Assisted the pharmacists with checking in and pricing drug orders, third party transactions and relevant paperwork
- Hand counted control medications, measured liquids and reconstituted antibiotics
- Effectively prioritized tasks and organized workflow to increase efficiency
- Complied with all federal laws, company policies and procedures and state regulations regarding intern, technician and assistant training and licensure.
Education
PharmD - Pharmacy
Creighton University
Omaha, NE01.2009
Skills
- Effective communication skills
- Passion for pharmacy practice
- Excellent English and technical writing proficiency
- Talent for simplifying complicated terms to make them more patient friendly
- Enthusiasm for team collaboration
- Eagerness to learn
- Embraces change
- Love for meeting new people and working with people from different backgrounds
Certification
- Nebraska license, 13176
- NPI number, 1477833010
- CPR certification
Timeline
Interim Clinical Criteria Pharmacist
Prime Therapeutics
2021.06 - 2022.11
Clinical Review Pharmacist Medicare Part D
Prime Therapeutics
2017.10 - Current
Pharmacist
Walgreens Pharmacy
2009.07 - 2018.04
Senior Pharmacy Technician and Pharmacist Intern
Walgreens Pharmacy
2000.10 - 2009.07
PharmD - Pharmacy
Creighton University
- Nebraska license, 13176
- NPI number, 1477833010
- CPR certification
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