Kristin Frans

HIM professional with 8+ years of experience across specialty pharmacy, prior authorization, appeals, benefit verification, and reimbursement operations. Proven leader with deep expertise in Medicare, Medicaid, and commercial payer structures, specialty pharmacy, PBM, and inpatient/outpatient procedure workflows. Recognized for coaching high-performing, geographically dispersed teams, driving operational excellence, and ensuring compassionate, compliant access to complex therapies.

Associate Benefit Analyst (Employer Install Specialist) at Benefits Operations Management (BOM) (2023-01 – Present)

Medicare Part D

• Analyze and interpret pharmacy benefit designs for commercial, Medicare, and Medicaid plans, including coverage limitations, exclusions, step therapy, and prior authorization requirements
• Conduct detailed benefit reviews and eligibility validations to determine patient coverage, cost‑share responsibilities, and reimbursement pathways
• Serve as a subject matter expert on payer policies, plan documents, and benefit configurations, translating complex benefit language into actionable guidance
• Support internal teams by resolving benefit discrepancies, access issues, and payer interpretation questions impacting authorization and claims outcomes
• Collaborate cross‑functionally with prior authorization, appeals, pharmacy operations, and client teams to ensure accurate benefit application
• Identify and document benefit‑related trends, inconsistencies, and payer variances that impact patient access and operational efficiency
• Review benefit changes, formulary updates, and payer policy revisions to ensure timely communication and operational readiness
• Provide clear, concise explanations of benefit determinations to internal stakeholders, providers, and patient‑facing teams
• Perform test claims and system validations to confirm benefit setup accuracy, copay calculations, and reimbursement routing
• Investigate and resolve complex benefit issues requiring coordination with PBMs, health plans, and external payer representatives
• Maintain accurate documentation of benefit determinations and resolutions in CRM and internal systems in compliance with audit standards
• Support financial access by identifying benefit limitations that may require prior authorization, appeal, or third‑party assistance pathways
• Ensure compliance with HIPAA, data privacy standards, and internal OptumRx policies when handling member and plan data
• Escalate systemic benefit issues and recommend process or system improvements to leadership and business partners
• Participate in benefit‑related training initiatives and share knowledge with peers as a trusted resource
• Contribute to process improvement efforts aimed at reducing access delays and improving benefit determination accuracy

Senior Pharmacy Prior Authorization/Appeals Technician at Specialty Medical Injectables (2020-01 – 2022-01)

Medicare, Medicaid, and Commercial - Pharmacy Prior Authorization – Medicare Part D

• Independently manage complex prior authorization and appeal requests for specialty, high‑cost, and medically complex prescription medications
• Conduct comprehensive benefit investigations across commercial, Medicare, and Medicaid plans to determine coverage requirements, limitations, and payer‑specific criteria
• Prepare, submit, and track initial PAs, reconsiderations, and multi‑level appeals, ensuring all clinical and administrative documentation meets payer standards
• Interpret medical records, clinical chart notes, laboratory results, and treatment history to support approval of pharmacy benefit requests
• Collaborate closely with pharmacists, nurses, prescribers, and provider office staff to obtain required clinical documentation and clarifications
• Demonstrate advanced knowledge of pharmacy and medical benefit structures, formulary requirements, step therapy, and medical necessity guidelines
• Draft and support Letters of Medical Necessity and appeal narratives in accordance with plan requirements and regulatory standards
• Execute test claims and electronic verifications of benefits to validate coverage, copay responsibility, and reimbursement pathways
• Apply working knowledge of CPT, HCPCS, and NDC coding to ensure accurate authorization and billing outcomes
• Follow up with PBMs, health plans, and third‑party vendors to obtain determination status, denial rationale, and next‑step requirements within defined SLAs
• Accurately document all payer, provider, and patient communications within CRM and authorization platforms in compliance with audit guidelines
• Assist patients and providers with understanding approval, denial, and appeal outcomes using clear and empathetic communication
• Support enrollment into manufacturer copay programs, foundations, and third‑party financial assistance when coverage barriers exist
• Maintain strict compliance with HIPAA, data privacy, and internal SOPs while handling sensitive patient and payer information
• Serve as a subject matter resource for peers by assisting with complex cases, payer navigation, and workflow questions
• Identify trends in denials, delays, or payer behavior and escalate systemic issues to leadership with recommended solutions
• Remain current on evolving payer policies, clinical guidelines, and therapeutic indications to support accurate authorization decisions
• Consistently meet or exceed productivity, quality, and turnaround time benchmarks in a fast‑paced, high‑volume environment
• Participate in process improvement initiatives, policy updates, and system enhancements to improve authorization outcomes and patient access

Senior Clinical Administrative Coordinator at Outpatient Procedure (2022-01 – 2023-01)

Medicare Part C, Dual

• Oversee end-to-end prior authorization, appeal, benefit verification, and third-party financial assistance processes for prescription drugs, infusions, medical devices, and procedures.

Supervisor, Pharmacy Prior Authorization at Pharmacy Prior Authorization (2017-01 – 2020-01)

Medicare Part D

• Supervised and developed a high-performing team of prior authorization agents in a fast-paced, high-volume call center environment supporting pharmacy benefit operations.
• Delivered consistent coaching, mentoring, and performance feedback to drive improvements in call quality, productivity, and first-call resolution.
• Conducted regular one-on-one meetings, performance evaluations, and development planning to support employee growth and engagement.
• Monitored key performance indicators (KPIs) including call quality scores, turnaround time, adherence, and service levels; implemented targeted action plans to address gaps and improve outcomes.
• Ensured strict adherence to HIPAA regulations, payer guidelines, and internal compliance standards across all operations.
• Partnered cross-functionally with clinical teams, QA, and operations leadership to resolve escalations, streamline workflows, and improve provider and member satisfaction.
• Supported onboarding and training of new hires, reinforcing best practices, scripting protocols, and system navigation.
• Identified process improvement opportunities and contributed to operational enhancements that increased efficiency and reduced authorization processing delays.
• Led teams focused on consumer engagement and service excellence, fostering a culture of accountability, collaboration, and continuous improvement.
• Supported member education, enrollment, and activation processes, helping individuals better understand and utilize their healthcare and pharmacy benefits.
• Guided team members in delivering empathetic, member-centered service using motivational communication techniques and personalized engagement strategies.
• Drove performance in structured, metric-based environments with responsibility for meeting and exceeding daily, weekly, and monthly production and quality goals.
• Analyzed performance data and trends to identify coaching opportunities, improve conversion rates, and enhance the overall member experience.
• Reinforced compliance with organizational policies, scripting requirements, and quality standards during all member interactions.
• Collaborated with leadership and support teams on special initiatives, campaigns, and seasonal efforts (e.g., enrollment periods), ensuring team readiness and successful execution.

Bachelor of Science in Health Information Management