Trang Le

• Reviewed and adjudicated Medicare Part D prior authorization and coverage determination requests in compliance with CMS guidelines and plan-specific criteria.
• Evaluated high-cost and specialty medications including oncology, rheumatology, endocrinology, GLP-1 therapies, and medical devices (CGMs) for clinical appropriateness and formulary compliance.
• Applied evidence-based clinical resources including Micromedex, NCCN Guidelines, Lexicomp, and biomedical literatures to support coverage determinations and off-label review.
• Interpreted patient chart notes, medical profiles, laboratory values, and diagnostic imaging to determine clinical appropriateness and medical necessity of therapy and alignment with FDA-approved and compendia-supported uses.
• Communicated coverage decisions and clinical rationale to providers' offices via electronic systems and outbound calls when necessary.
• Participated actively in peer-to peer discussions, huddles, team meetings, and escalated complex cases to Subject Matter Experts (SMEs) and managers.
• Maintained productivity benchmarks while ensuring accuracy and compliance.
• Documented case reviews clearly and concisely within electronic authorization platforms.

- Managed daily pharmacy operations, ensuring compliance with Federal and State regulations, insurance plans, and company policies.

- Provided clinical services including but not limited to immunizations, Point-of-Care testing, patient education on medications and medical devices' uses, Comprehensive and Targeted Medication Reviews (CMR and TMR) via OutcomesMTM platform, and patient outreach services to improve medication adherence.

- Ensured accurate, safe, and efficient prescription dispensing and made outbound calls to prescribers to address any potential treatments' discrepancies and/or therapeutic alternatives when necessary.
- Provided effectively structured feedback to staff, encouraged open communication and team engagement, and supported individual and team growth, enhancing team performance and customer service quality.
- Created a comprehensive list of daily, weekly, monthly tasks, prioritized based on urgency, and delegated with effective supervision.
- Analyzed performance metrics and company goals, identified areas of improvement, then created an effective action plan with clear priorities and expectations.
- Resolved any internal and external conflicts with empathy and active listening.

• Provided personalized, high-touch care including medication synchronization, home delivery, and clinical services like immunizations, Medication Therapy Management (MTM), health screenings, and compounding.
• Handled billing, insurances, and assisted in customer relations.
• Optimized inventory, including but not limited to reducing waste (MatchRX, manufacturer return policies), and implementing first-in-first-out inventory rotation system, leveraging software (Liberty) to generate the daily ordering list.
• Educated all staff to interact with customers respectfully and efficiently.