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Click here or scroll down to respond to this candidateCandidate's Name
Roanoke, TX PHONE NUMBER AVAILABLEEMAIL AVAILABLEProduct Test Consultant; Quality Engineering & AssuranceEXPERIENCEAPRIL 2023 PRESENTQUALITY ASSURANCE ENGINEER, TATA CONSULTANCY SERVICESJob Responsibilities: Conducts functional and UAT testing and technical analysis for RxClaims PBM software Uses business specifications and clinical UM requirements to translate pharmacy rules and processes into functional test cases. Uses professional skills and understanding of the pharmacy/PBM industry, including laws and regulations, to create relevant scenarios necessary for accurate test bed design, execution, and validation.*Experience working on Commercial, Medicaid, Medicare, and EGWP plans*Experience working for CVS client on clinical and benefit test cases for BCBSTN and BCBSMAMAY 2018 MARCH 2023LEAD QUALITY ASSURANCE ENGINEER, cognizant technology solutionsJob Responsibilities: Conducts functional and UAT testing and technical analysis for RxClaims PBM software Uses business specifications and clinical UM requirements to translate pharmacy rules and processes into functional test cases. Uses professional skills and understanding of the pharmacy/PBM industry, including laws and regulations, to create relevant scenarios necessary for accurate test bed design, execution, and validation. Experience working both independently and collaboratively on all areas of testing pertaining to the CVS Anthem migration project including: Benefits, Clinical UM, Formulary, DUR, Claims, PA, Certification, and Model Office testing, in both pre- production, and production environments. Experience working on New Business Implementation Team (NBI) to conduct clinical benefits testing for CVS new business clients. Experience working on Formulary Management Systems Team (FMS) to conduct research and analysis for formulary migration. Experience working on EGWP Team, conducting clinical and benefit testing for group Medicare Advantage plans. Worked with CVS leadership on section 204 of the Consolidated Appropriations Act Prescription Drug Cost Report of 2021 (CAA RxDC) to gather, analyze, and submit required drug cost reports per CMS protocol**Experience working on Commercial, Medicaid, Medicare, and EGWP plans Assures product consistency while adhering to strict delivery schedules, to expedite and ensure the seamless migration of large PBM clients and data.Skills Used:Microsoft Office, Sequel, Salesforce (SFDC), AS400, EzQuery, RxClaims, Sharepoint, WinSCPOCTOBER 2017 APRIL 2018DATA VERIFICATION SPECIALIST, Cardinal HealthJob Responsibilities: Provide Accurate verification of customer insurance benefits obtained via phone or web verify most recent deductible, copay, coinsurance or out of pocket accumulations for each account in question Verification of coverage of supplies ordered Verification of network participation with the customer's insurance plan Knowledge of financial processes, systems, controls, and work streams. Worked collaboratively in a finance environment coupled with strong internal controls. Understand service level goals and objectives when providing customer support. Respond to non-standard requests from vendors and customers. Possess strong organizational skills and prioritize getting the right things done. Audit claims as necessary per CMS guidelines/regulations and company SOP's Identify billing and coding discrepanciesSkills Used:Microsoft Office, Emdeon (Change Healthcare), Availity, NaviNet, RGH, Insurance specific provider portals used for accessing real-time benefits authorization/claims adjudication, e.g., BCBS-Web Denis, Humana, Aetna, Coventry, UnitedHealth Care & its subsidiaries, Ambetter, Centene, Sunshine Health, Allwell, CMS, EmblemHealth, TennCare, Ky Passport, etcAUGUST 2014 AUGUST 2017PHARMACY FIELD AUDIT SPECIALIST, NorthStar HealthCare ConsultingJob Responsibilities: Review pharmacy claims for compliance with client policy and state or federal guidelines and laws. Knowledge of the PBM industry, formulary management, DUR clinical programs, pharmacy claims and managed care principles and practices. Perform retrospective claims review to identify program compliance. Identify suspected pharmacy fraud and abuse from claims data. Work closely with pharmacy audit personnel in conducting claims review. Work closely with the analytics support specialist to develop and provide reports for clients. Analyze trends in drug utilization patterns and costs. Work closely with Program Compliance team to develop, test, improve, and implement pharmacy audit programs. Provide insights and valuable contributions to the development of audit-based algorithms and scorecards. Detect data problems by executing computerized database queries. Provide information by collecting, analyzing, and summarizing data and trends. Enhance clinical data department and organization reputation by accepting ownership for accomplishing new and different requests. Recognize, summarize, and refer possible fraud related activities found within the pharmacy to appropriate government officials. Other duties as assigned by management.Skills UsedMicrosoft Office, RxClaims, PioneerRx, Intercom Plus, Surescripts, and other proprietary audit programs for the use of claims analysis, reimbursement, and reconciliation purposes.APRIL 2014 AUGUST 2014PBM HOSPICE ACCOUNT MANAGER, ProCare RxJob responsibilities:Provide daily and ongoing support for hospice administration. Assist pharmacies with claims adjudication errors and approve prior authorizations for hospice covered medication as needed. Perform pharmacy analysis assignments based on the specifications requested by client or department. Investigate and resolve claims disputes between hospice and contracted pharmacy, and submit error reports as needed. Investigate and submit MAC disputes based on contracted pharmacy rates, dispense dates, and pharmacy invoices. Provide formulary management for hospice plans based on patient disease state, client, administrative preference, CMS compliance, and clinical recommendation.Skills Used:The use of multiple proprietary software programs such as, eProcare, Admit24, DMW, CMW, RR, and ProcareRX, in conjunction with SugarCRM, and Microsoft Office.JUNE 2013 APRIL 2014IMPLEMENTATION SPECIALIST, AlixaRxJob responsibilities: Implement and provide support for pharmacy services and ADU (automated dispensing unit) Implementations as they relate to all aspects of medication management in nursing facilities. Serve as the primary resource for training long term care facility personnel. Evaluate implementation and support conversion form previous pharmacy to new pharmacy. Deliver coaching and feedback to implementation team members to assure optimal team performance. Complete medication cart audits with the utilization of Medication Administration Reports (MAR), and federal/state regulations. Create educational materials for the purpose of in-servicing nursing home staff and administration. Schedule and conduct in-services for nursing home staff and administration on topics related to Remote pharmacy operations, software upgrades, and ADU policies and procedures. Complete facility profile, technology and service assessment. Apply understanding and familiarity with pharmacy regulations to support successful ADU implementation. Coordinate the order and delivery of Med Carts with Operation Support Team. Complete acceptance criteria and related reports and test automated dispensing unit (ADU) prior to implementation.Skills Used:Microsoft Office, Docu Track, FrameworkLTC, proprietary software relating to ADU and remote pharmacyoperationDECEMBER 2011 JUNE 2013SENIOR CERTIFIED PHARMACY TECHNICIAN (CPHT), CVS HealthJob Responsibilities: Prepare and fill prescriptions. Perform data entry for hard-copy, facsimile, and electronic prescriptions. Bill insurance companies and resolve insurance related issues. Reconstitute medications. Maintain inventory and submit daily orders to suppliers. Communicate with prescribing physicians to verify new prescriptions and update existing refill requests. Pull and return out-of-date medications to appropriate vendors. Maintain customer relations and monitor patient prescription compliance. Internal and external audit participation and preparation.APRIL 2011 SEPTEMBER 2011PHARMACY BENEFITS MANAGER AND PRIOR AUTHORIZATION SPECIALIST, CPHT, Coventry HealthcareJob Responsibilities: Pharmacy Benefits Management for Gallagher Bassett. Provide customer service for the pharmacy division of workers compensation at Coventry Healthcare. Process prior-authorization requests and update billing information for pharmacies. Work directly with insurance adjusters and pharmacists to approve medications for injured workers.APRIL 2007 MAY 2008SENIOR CERTIFIED PHARMACY TECHNICIAN (CPHT), Kindred Pharmaceutical Services/Pharmerica CorporationJob Responsibilities: Fill prescription in both unit and bulk Prepare IV admixtures, and compound medications Stock medication Check and pull expired drugs Manage inventory Verify shipping container with log sheetEDUCATIONMAY 2015AAS IN HEALTH SCIENCESouthern New Hampshire UniversityMARCH 2007CERTIFICATEFortis CollegeMAY 2001HIGH SCHOOL DIPLOMASabino High SchoolSKILLSFunctional TestingSugarCRMMedical InsuranceFramework LTCAS400Insurance VerificationManaged CarePharmacy Claims AnalysisUser Acceptance TestingMedCoQS/1 Data SystemsPharmacy AuditingFormulary and PDL ManagementPioneer RxPharmacy Technician ExperienceQuality AssuranceSDLCCMWRisxfacsAdmit24Quality EngineeringEzQueryMicrosoft OfficePrior AuthorizationSalesforce (SFDC)SequeleProcareMedical BillingDrug Utilization Review and ManagementRxClaimsManual Test CasesAgileInternal AuditsRequirements GatheringCERTIFICATIONS AND LICENSESCPhTFebruary 2009 to June 2023Nationally Certified Pharmacy Technician through the PTCB. License/Certification No: 470101090259076Registered Pharmacy TechnicianJanuary 2012 to June 2023Registered Pharmacy Technician in the State of GeorgiaGROUPSACFE2015 to PresentAssociation of Certified Fraud ExaminersNADDI2015 to PresentNational Association of Drug Diversion InvestigatorsNSCS2015 to PresentNational Society of Collegiate Scholars |
