Pharmacy Operations Rep - HCSC
(2024-08)
- Resolved complex pharmacy claims, pricing discrepancies, and coding issues for customer service teams, pharmacy coordinators, pharmacists, and members.
- Collaborated with internal departments and external vendors to investigate and resolve pharmacy-related concerns, ensuring timely and accurate outcomes.
- Assisted in evaluating claim processing workflows to identify inefficiencies and recommend improvements for operational effectiveness.
- Maintained compliance with regulatory standards by documenting resolutions and ensuring adherence to pharmacy policies and procedures.
- Delivered clear communication and guidance to stakeholders, enhancing customer satisfaction and strengthening cross-functional relationships.
- Facilitated Medication Therapy Management (MTM) by coordinating with pharmacists to review patient medication regimens, identify therapy gaps, and support interventions that improve adherence and clinical outcomes.
Pharmacy Operations Specialist - Wellsense Health Plan - Boston, MA
(2024-01 - 2024-07)
- Processed and reviewed prior authorization requests via fax, phone, and electronic systems in compliance with regulatory and accreditation standards.
- Applied clinical policy criteria to authorization reviews and interpreted member eligibility, claim history, and pharmacy program data.
- Communicated determinations to members and providers through calls, faxes, and letters.
- Entered and validated medical and pharmacy data in accordance with NCQA accreditation requirements.
- Provided pharmacy-related customer service to internal and external stakeholders.
Pharmacy Benefits Coordinator - Paydhealth - Dallas, TX
(2020-07 - 2024-01)
- Adjudicated pharmacy claims, resolved processing issues, and ensured accuracy of quantity and day supply.
- Reviewed prior authorization cases for completeness and compliance with PBM formulary criteria.
- Served as primary contact for enrollment tasks and inquiries, ensuring timely resolution.
- Conducted benefits investigations and identified patient assistance opportunities to reduce out-of-pocket costs.
- Built strong relationships with pharmacies and providers to streamline claims processing.
- Analyzed claim data to identify trends, recommend cost-saving measures, and improve program efficiency.
Sr. Coordinator – Individualized Care - Cardinal Health - Lewisville, TX
(2019-01 - 2020-07)
- Managed inbound/outbound calls with patients, providers, and payers to resolve inquiries.
- Reviewed patient assistance applications and coordinated access to therapy.
- Investigated claim issues and conducted benefits investigations with payers.
- Assisted patients with foundation programs and coordinated pharmacy care for positive drug therapy outcomes.
CPHT III PBM Operations Specialist - DaVitaRx - Coppell, TX
(2015-07 - 2018-12)
- Reviewed non-formulary and prior authorization requests against plan criteria.
- Escalated formulary exceptions to pharmacists and documented findings for clinical teams.
- Conducted audits to identify fraudulent activities and recommended preventive measures.
- Developed SOPs to improve operational efficiency and staff performance.
- Triaged patient calls for pharmacist-led medication reviews.
Configuration Analyst (CPHT Rep III) - CVS Health - Richardson, TX
(2010-03 - 2015-07)
- Managed plan benefits GPI coding, configuration changes, and testing.
- Conducted user acceptance testing for new configuration logic.
- Reviewed formulary data files and maintained client documentation.
- Collaborated with cross-functional teams to ensure accurate benefit design implementation.
Certified Pharmacy Technician - Walgreens - Murphy, TX
(2010-02 - 2012-01)
- Processed prescriptions, performed data entry, and managed inventory.
- Assisted patients with prescription issues and prior authorization requests.
- Adjudicated third-party claim rejections and explained benefits to patients.
