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Click here or scroll down to respond to this candidateCandidate's Name
Over Street Address years of Call Center, Mail Order and Specialty Pharmacymanagement experience along with PBM and HUB Programs. 2057 Milkweed StreetOcoee, FL 34761PHONE NUMBER AVAILABLEEMAIL AVAILABLEEXPERIENCEBioPlus Specialty Pharmacy/Elevance Health Orlando, FL Patient Care Services Manager IINovember 2020 - March 2024Development and implementation of departmental policies, SOPs, internal process flows and quality improvement initiatives for the 7 specialty pharmacy call centersOversight of the Pharmacy Customer Associate Manager Is, Team Leads and over 70 PCCs to ensure maximization of the organizations resources as well as hire and train Pharmacy Customer Associates to exceed expected goals and metricAct as a SME/liaison for all Pharmacy operations functions for internal and external patients, providers, outside vendors and contracted referral sourcesProvide tracking and analytics to Senior Leadership on performance KPIs, PGs, SLAs and participates in the performance improvement planning using Power BI and Rhythm SystemEnsure Pharmacy compliance in accordance with all accreditation programs and regulatory bodies (URAC, CMS, ACHC, NASP and NABP) Successful management of complex therapies for Oncology, Infusion, Multiple Sclerosis, HIV/AIDS, HCV, Hemo, Transplant, RA/OA and other biologics for chronic health conditions for clinical appropriateness and revenue cycle optimizationKabaFusion Huntsville, ALPatient Care ManagerMay 2020 - November 2020Coordinated sourcing and scheduling of 7 Clinical Field Nurses for Infusion, Specialty Therapy and Obstetric home nursing care Report and track timely submission of outsourced Clinical Field Nursing EMR and invoices to corporate Accounts PayableManages the Clinical and Administrative Intake Staff to ensure Payer reimbursement, benefit determination, coding and authorization adherenceSKILLSRegistered PharmacyTechnician familiarwith all aspects ofpharmacy/healthcareoperations. Proficientin benefit andprogram developmentas well as front andback-end pharmacyoperations.Specialized in qualityassurance, trainingfor accredited auditprograms andworkforcemanagement.Knowledge ofcontract negotiations,benefit design andclient integration.LANGUAGESEnglishMaintain standard of care continuum staff training Processes Clinical Field Nursing staff and Administrative payroll Collaborates with sales team to ensure corporate KPIs and patient care goals are metMagellan Pharmacy Orlando, FLHome Delivery Operations ManagerJanuary 2019 - March 2020Manages day to day Mail Order Pharmacy front and back-end staff of 16 Technicians and Supervisors utilizing ScriptPro, CPR+, IEX and other healthcare platformsForecasts, analyzes data and prepares pharmacy related reports and presentations for executive teamAssists with integrating pharmacy functions within the departments (e.g., Quality, Case Management, Provider Relations) within pharmacology standardsBuilds and approves SOP, KPIs and training documents Manages clinical staff activities surrounding new implementations and lines of businessMaintains State of Florida Pharmacy Technician Registration CVS Health Orlando, FLPharmacy Operations SupervisorNovember 2015 - January 2019Oversee a team of 30 Registered/Certified Pharmacy Technicians to comply with National/State Pharmacology law along with entry production compliant with CVS Quality StandardsWorkforce and call management adherence using Avaya, CMS, Mattersight, NICE, Genesys Cloud, Mitel and Verint programs Instituted and manage the CVS Health Onboarding Technician Training ProgramChairperson of CVS Health CRGClient Services Team LeadManage a team of 16 Financial Assistance Specialists dedicated to our manufacturer partners to provide Brand support and cost containment programsProcedural accounting in accordance with Advanced Care Scripts, Inc/Omnicare/CVS and manufacturer DED program guidelines Direct interaction with our CVS partners, pharma programs, pharmacies and patientsReporting trends and outcomes to set department staffing needs and work assignmentsFacilitate interdepartmental cross-training and SLT meetings Aetna Specialty Pharmacy Orlando, FLSenior Quality ConsultantMarch 2007 - November 2015Conducted standard quality reviews/audits to measure compliance Supported targeted quality audit projectsReported results and recommendations for training needs, quality controls and process improvementSubject matter expert on workflows, policies, system requirements/enhancements for daily operations for dispensing specialty pharmacyPerformed root cause analysis and/or analyze data to identify operational trendsForecasted business activity results and recommended ideas for the development of quality control policies and procedures Managed the Aetna Med D members transition from the MOD platform to the specialty pharmacy businessAudited financial assistance compatibility between Med D specialty members and third party payorsPharmacy Operations TrainerDeveloped and facilitated training sessions to designated audiences; collaborated with supervisors and managers to create curricula specific to the departmental needsManaged all aspects of employee performance and quality auditing to help identify gaps, appropriate training interventions and other variables required to improve business performanceClaims Benefit SpecialistApplied medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies and administer all cost containment measures to assist in the claims billing and collections processTriaged and proofed complex claims or referral sources financial reconciliation, coding including diagnostic and procedural, member and provider identification processesUtilized all applicable system functions to ensure accurate and timely claim processing and invoice follow upPriority Healthcare/ESI Lake Mary, FLInsurance Coordinator/Reimbursement SpecialistSeptember 2000 - March 2007Managed complete front-end verification of insurance benefits for specialty biopharmaceutical companyObtained prior authorization/precertification, determined medical necessity based off clinical documentationReconciled PBM rejections with online adjudication to multiple payors Reimbursement reconciliation, posted receivables with emphasis on pended or denied claimsManaged aggressive collections program on aged accounts receivables EDUCATIONClovis, NMOTPEastern New Mexico UniversityA.A DegreeBusiness AdministrationPharmacy Technician UniversityRegistered Pharmacy Technician2019PROJECTSOrlando Integration - EmpiRx Health PBM2024Launched the Orlando Clinical Operations Specialist Team for PBM EmpiRx Health. Used key initiatives to build out processes and workows for integrating new and existing EH clients. Hired, trained and supported the Clin Ops Team on acclimating to the new facility using proprietary technology. |
