Tanya Smith
Lavista,USA
Summary
Experienced Pharmacy Technician with over 20 years of expertise in the healthcare industry, specializing in medication therapy management, prior authorization processing, and claims resolution. Adept in managing pharmacy operations, overseeing PBM functions, and ensuring compliance with Medicare Part D, B, and commercial insurance plans. Strong background in training, leadership, and fostering excellent customer service. Seeking a position in account management or other clinical opportunities at a PBM to utilize my skills in data analysis, problem-solving, and client relationship management.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Clinical Services Specialist
Aspire Health Plan
10.2020 - Current
- Processed and resolved Part D grievances, ensuring compliance with CMS guidelines and timely resolution of member issues.
- Managed claims oversight, collaborating with PBM to ensure accurate claims processing, adherence to Medicare Part D formulary, and proper payment determinations for Part B medications.
- Conducted bi-monthly audits of Prescription Drug Event (PDE) reports, addressing errors and ensuring CMS compliance, improving reporting accuracy.
- Reviewed and updated formulary, Step Therapy, and Prior Authorization protocols, ensuring marketing materials were accurate, compliant, and reflective of current standards.
- Entered cases for prior authorization review of medications under Part B benefits, ensuring timely processing and accurate decision-making.
- Conducted outbound calls to pharmacies to process 100-day supplies of maintenance medications, directly contributing to improved STARS measures related to medication adherence.
- Created and maintained Standard Operating Procedures (SOPs) for clinical processes, ensuring consistency, efficiency, and effective PBM oversight.
- Provided annual Medicare Part D training and ad-hoc sessions for staff, ensuring alignment with current regulations and best practices.
- Performed audits on coverage determinations, grievances, and redeterminations, maintaining high standards for accuracy, compliance, and timeliness.
- Followed-through on all critical inter-departmental escalations to increase customer retention rates.
Pharmacy Technician Instructor
Metropolitan Community College
07.2022 - 08.2023
- Developed and delivered instructional materials to prepare students for the Pharmacy Technician Certification Exam (PTCE). All 60 students who took the class passed the PTCE.
- Evaluated students' competencies through written assignments and examinations.
- Updated instructional materials, ordered equipment and supplies, and utilized various learning modalities to enhance instruction.
- Taught courses on pharmaceutical math, medical terminology, and compounding, preparing students for careers in various pharmacy settings.
Clinical Programs Supervisor
CastiaRx/OptumRx
03.2012 - 01.2021
- Reviewed and approved medication prior authorization requests, utilizing clinical protocols and patient data for Medicare and commercial plans.
- Trained and mentored pharmacy technicians and clinical staff on the proper use of PA Hub and RxClaim software for prior authorizations and claims processing.
- Coordinated internal audits for prior authorizations, ensuring adherence to CMS regulations and clinical guidelines.
- Supervised clinical department activities, delegating tasks to technicians and ensuring timely, accurate completion of responsibilities.
- Led investigation and resolution of 100 grievances and managed direct member reimbursements (DMR).
- Managed team performance through regular coaching, performance reviews, and recruitment of new clinical specialists.
- Proven ability to learn quickly and adapt to new situations.
- Demonstrated strong organizational and time management skills while managing multiple projects.
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
Education
Master of Forensic Science - Forensic Science
Nebraska Wesleyan University
Lincoln, NE12.2006
Bachelor of Science - Biology and Chemistry
College of Saint Mary
Omaha, NE05.2003
Skills
- Attention to detail
- Clinical documentation and applications
- Customer service excellence
- Communication
- Excellent time management
- Quick problem solver
- Adaptable
- Critical Thinking
- Electronic health records
- Analytical decision-making skills
- Medical terminology
- Software proficiency: Microsoft Office Suite (Word, Excel, and PowerPoint), EPIC, PaHub, RxClaim, Rx30, Telemetry Rx, CIM, MedAccess
Certification
- Certified Pharmacy Technician, Pharmacy Technician Certification Board (PTCB), 11/01/02, Current
- Pharmacy Technician Licensed, Nebraska, 1/2008, Current
References
Available upon request
Timeline
Pharmacy Technician Instructor
Metropolitan Community College
07.2022 - 08.2023
Clinical Services Specialist
Aspire Health Plan
10.2020 - Current
Clinical Programs Supervisor
CastiaRx/OptumRx
03.2012 - 01.2021
Master of Forensic Science - Forensic Science
Nebraska Wesleyan University
Bachelor of Science - Biology and Chemistry
College of Saint Mary
Similar Profiles
Julie GarciaJulie Garcia
Care Coordinator I at Central California Alliance for HealthCare Coordinator I at Central California Alliance for Health
Rebecca RossRebecca Ross
Transition Care Coordinator at Virginia Premier Health Plan/Sentara Health PlanTransition Care Coordinator at Virginia Premier Health Plan/Sentara Health Plan
Sheila KaneSheila Kane
RN Case Manager III at Dean Health Plan; Dean Health Plan by MedicaRN Case Manager III at Dean Health Plan; Dean Health Plan by Medica
Denise ErvinDenise Ervin
Bartender at Omaha Performing ArtsBartender at Omaha Performing Arts
Kristopher HeigKristopher Heig
Compliance Solutions manager at Amplify TechnologyCompliance Solutions manager at Amplify Technology