John Paul Maraña

Detail-oriented Claims Specialist with experience in long-term care pharmacy claims processing and adjudication, mainly focused on reviewing and resolving pharmacy claim rejections, investigating payer rejection messages, correcting claim information, and resubmitting claims when appropriate. Skilled in working with Medicare Part D coverage requirements, coordinating with insurance providers and healthcare teams, and maintaining accurate claim documentation while managing high-volume workloads.

Claims Specialist at Ascendance BPO Inc. — Client: MedWiz Pharmacy (2023-11 – 2026-07)

• Processed prescription orders written by prescribers for residents of nursing homes and assisted living facilities and submitted the associated electronic pharmacy claims to prescription drug plans for adjudication.
• Reviewed prescription and patient information in the pharmacy system to ensure the claim contained accurate information before submission.
• Submitted pharmacy claims to Medicare Part D and Medicaid prescription drug plans and reviewed the payer's adjudication response.
• Investigated rejected claims by analyzing payer rejection messages and identifying the underlying issue or coverage requirement.
• Corrected claim information when the issue was within scope and resubmitted the claim for adjudication.
• Handled Medicare Part D rejections involving refill-too-soon, prior authorization, formulary restrictions, coverage limitations, quantity, and day-supply requirements.
• Contacted prescription drug plans to clarify rejection reasons, verify coverage requirements, and request available overrides or reversals when appropriate.
• Coordinated with pharmacists and nursing staff when clarification was needed regarding prescription or medication information.
• Responded to healthcare team inquiries regarding prescription claim status, rejection reasons, and required follow-up.
• Documented claim processing activities, payer communications, corrections, and resolutions for accurate follow-up and compliance.
• Managed a high-volume prescription claims workload while maintaining accuracy, productivity, and quality expectations.

Bachelor of Science in Information Technology – Nueva Ecija University of Science and Technology (2019 – 2023)