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Work Background
Pharmacy Benefit ManagerClinical Specialist
Jun. 2024• Provide comprehensive account support to internal EmpiRx Health teams, overseeing adjudication, clinical review, and claims-related matters while fostering strong communication and collaboration across all departments to ensure a unified approach.
• Manage claims overrides and prior authorization support, delivering exceptional white-glove service to clients and members, with a commitment to addressing escalation requests within a 2-hour turnaround time.
• Demonstrate proficiency in Tredium PBM claims software and JMT ticketing systems, ensuring efficient and accurate claims processing.
• Participate in Saturday rotations and provide on-call support on Sundays for urgent claim overrides, demonstrating reliability and commitment to service.
• Conduct test claims with pre- and post-approval dates to verify claim accuracy and ensure compliance with established guidelines.
• Utilize appropriate communication channels, such as fax and phone calls, to follow up on prior authorization requirements and ensure timely resolution.
• Place overrides for tickets escalated to the ClinOps team, including issues related to Days Supply Limit, Quantity Limit Exceeded, Formulary Exclusion, Step Therapy, and more.
Health FirstPharmacy Technician III
Sep. 2021 - May. 2024Melbourne, Florida, United States• Tasked with efficiently assessing and resolving billing issues in coordination with insurance companies, ensuring timely and accurate payments. • Initiated and investigated pending prior authorization approvals through calls to insurance companies or the Cover My Meds portal.
• Collaborated directly with health plans to coordinate medication rejects/authorization approvals, prioritizing the best patient outcomes.
• Facilitated effective communication with nursing and medical staff to ascertain timely patient discharge and maintained smooth workflow transitions for associates based on business needs.
• Served as a home infusion liaison, coordinating safe patient discharge between case managers, home health services, Carepath, and pharmacy teams.
• Facilitated training associates on EnterpriseRx, SCM (Sunrise Clinical Manager), Telmediq, Teams, and CoverMyMeds systems.
• Delivered medications and supplies to patient rooms and ancillary areas according to established procedures. • Aligned home delivery with mailroom staff using couriers, USPS, or FedEx.
• Communicated patient care needs effectively with staff members through Teams and Enterprise Rx Notes.
Publix Super MarketsLead Certified Hospital Pharmacy Technician
Mar. 2007 - Sep. 2021Orlando, Florida, United States• Recognized for assessing and resolving billing issues through effective coordination with insurance companies. • Carried out thorough investigation prior authorization approvals and payments via calls to insurance companies or through the Cover My Meds portal.
• Secured authorization for the procurement of specialty medications from drug companies. • Assumed responsibility for counting and balancing tills, depositing funds securely, and ordering cash from the bank. • Created schedules that aligned with business needs while accommodating time off requests for technicians and interns.
• Exemplified the organization during physician and nurse rounds, providing exceptional service to meet and exceed the needs of discharged and infusion patients in collaboration with Publix and Nemours.
• Acquired and utilized extensive knowledge of specialty medications, biologics, and injectables.
• Transitioned back to regular retail/wholesale operations after inventory depletion.
• Attained 100% employee participation in flu vaccinations, demonstrating commitment to health and safety within the team.
• Spearheaded successful inventory management initiatives, including medication ordering, returns, and inter-store transfers, ensuring optimal stock levels and minimal discrepancies.
• Trained six new associates with a strong emphasis on maximizing productivity and operational efficiency, contributing to the overall success of the team.
• Supervised billing and inventory procedures across the company, ensuring smooth and efficient workflows.
• Enhanced scores by completing TIPS and efficiently scheduling Comprehensive Medication Reviews (CMRs) for pharmacists.
Publix Super MarketsCertified Pharmacy Technician
Mar. 2007 - Sep. 2021Orlando, Florida
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