Rainier Rocafort

• Worked on several major projects related to development and configuration of new business, member benefits, products, claims editing, reference data, and their enhancements including claims configuration improvements, compliance, and systems enhancements.
• Interpret specific state and/or federal benefits, contracts as well as additional business requirements and convert these terms to claims configuration setup parameters.
• Benefit configuration in Medicaid, Medicare, and Commercial Line of business as well as Quality Assurance, testing validation for production.
• Claim configuration management policies, procedures, and tools. Assist with development of claims configuration standards and best practices.
• Develop clear, concise documentation that describes claims configuration defect trends so that this information can be used to develop workflow requirements
• Responsible for quality and integrity of claims configuration change requests through the use of production validation and audit strategies.
• Responsible for organizing release of claims configuration changes to production to reduce potential for migration conflict.
• Responsible for presenting and demonstrating configuration to clients in all Line of Business and final approval.

• Lead and deliver several major pharmacy projects related to development and configuration of new business, member benefits, products, claims editing, reference data, and their enhancements including claims configuration improvements, compliance, and systems enhancements.
• Configuration of all levels of client benefit design within the PBM Express Software Platform.
• Benefit Configuration documentation, troubleshooting configuration, and adjudication issues.
• Data analysis, interpretation, system logic, claims payment processing, and adjudication.
• Plan Quality Assurance validation to ensure compliance with regulatory and audits controls.
• Quality Analysis and Postproduction Audits of benefit design to assure proper guideline measures and accuracy.
• Responsible for interpretation, configuration operation analysis of new client business requirements from retail pharmacies, Health Plans, and Wellness business units,
• Subject Matter Expert with direct client contact for Medicare/Medicaid/Commercial Health plans/Pharmacy discount cards (GoodRx, Hola Doctor, etc.,) for interpretation, configuration, and reporting.
• Trained and provided support for newly hired configuration Analysts.

Responsible for paid claim analysis and adjudication, Data collection related to PBM operational activities for both commercial and Medicare/Medicaid

• Assist with clinical and compliance monitoring of PBM operations.
• Monitor and analyze daily reject reports with a focus on prescriber and medication utilization-related issues.
• Commercial, Medicare/Medicaid paid claims analysis and adjudication issues.
• Reviewer of Opioid over-utilization program. Provided report to pharmacy management.
• Able to correct 100% of reject pharmacy adjudication by providing reports to analysts for configuration errors and/or pharmacy incorrect code input.
• Performed Quality Assurance validation processes to comply with regulatory and audit controls.
• Worked closely with the Director of Operations to maintain optimum levels of communication to effectively and efficiently complete projects.