Jessica Claire
  • , , 100 Montgomery St. 10th Floor
  • H: (555) 432-1000
  • C:
  • Date of Birth:
  • India:
  • :
  • single:
Professional Summary

Dedicated Pharmacy Manager enthusiastic about helping diverse people and offering experience with regulatory requirements. Knowledgeable in Medicare Part C and D Prior Authorization, Appeals and Grievances improving processes, maximizing team productivity and [Area of expertise]. Bringing successful career history comprising more than 20 years.

  • Time Management
  • Excellent Verbal and Written Communication
  • Critical Thinking
  • Process Implementation
  • Employee Performance Evaluations
  • Medicare Compliance
  • Proficient in Microsoft Office Applications (Excel, Word, PowerPoint, Outlook, OneNote)
  • Proficient in electronic drug information databases (Drugdex, Lexicomp, NCCN, PubMed)
Professional Experience
Pharmacy Manager, Medicare Part D Appeals , 04/2016 - 09/2021
United Healthcare City, STATE,

· Overseeing a team of pharmacists performing Medicare Part C & D pharmacy appeal clinical reviews. process consistent, accurate, and timely Appeals and High Cost Drug Prior Authorizations


· Working closely with Regulatory & Compliance teams to interpret and implement new Medicare Part C & D changes related to Redetermination and Reconsiderations.

· Provide support in clinical and claim reviews during various CMS and external audits.

· Design and implement internal focus audits to identify and remediate performance gaps.

· Innovative automations utilizing macros and SharePoint sites to streamline processes, create reporting for further analysis and decrease potential errors.

· Oversee the process of Independent Review Entity reviews and re-openings and collaborating closely with senior Medical Director and other external teams to implement process improvements

· Educating providers on plan benefit design and providing alternative drug therapies.

· Extensive experience with tracking, researching and analyzing new operational/regulatory requirements

· implement strategies to minimize risk of IRE overturn decisions and decrease the count of auto-forward redeterminations

Clinical Pharmacist, Pharmacy Prior Authorization, 10/2015 - 04/2016
Molina Healthcare City, STATE,
  • Created denial verbiage template compliant with Medicaid Regulatory Requirements to ensure accuracy and consistency in communicating prior authorization decisions to members and providers.
  • Created Policy & Procedures (P&P) for reviewing prior authorization requests for non-formulary drugs, narcotic analgesics as well as exceeding plan quantity limit to create consistency amongst reviewing pharmacists.
  • Developing utilization management criteria based on standard of practice and presenting at pre-P&T committee
Manager, Clinical Services Quality and Compliance, 01/2008 - 10/2015
OptumRx Pharmacy Clinical Services City, STATE,

Oversee a team of pharmacists performing inter-reviewer reliability audits, identifying deficiencies, and implementing process improvements within Prior Authorization, Appeals and Formulary Management. Designed and managed various internal audits to ensure quality and compliance with Federal and State Regulatory requirements.

  • Created and maintain department Policy & Procedures and presented at National Pharmacy & Therapeutics Committee (NP&T) for annual approval.
  • Participated in various external CMS and Client-Specific audits providing Compliance and Operational support.
  • Conducting performance evaluations, coaching and feedback to staff
  • Rendered Appeal & Grievances clinical decisions by collaborating closely with on-site Medical Directors during the transition process.
  • Created member/provider letter templates, and databases to generate compliant reports
  • Prepared Appeals & Grievances case files for CMS and client-specific audits, lead CMS Data Validation Audit interviews and remediate Corrective Actions.
  • Led a quality process (Inter-Rater Reliability audit) by facilitating discussion amongst leaders from multiple departments in order to enhance Prior Authorization guidelines and clinical decision making
  • Completed focus audits on High Cost Medications (for example, Cialis and Oral Hepatitis C drugs) to provide clinical program efficiency and lowering program costs
  • Routinely provided training feedback for up to 15+ Prior Authorization Managers/Supervisors and 300+ pharmacists on clinical guideline use, Job Aid updates, regulatory guidance and pharmacist verbiage templates
  • Assisted in the review, contrast, analysis, and update of the Clinical Services Policy and Procedures for presentation to the Clinical Programs Sub-committee of the National Pharmacy and Therapeutics Committee
  • Presented summary and analysis of quality improvement programs to OptumRx leadership at the Clinical Quality Oversight Committee meeting
  • Repeated success in leading quality processes to ultimately reduce the cost of administering health care to membership while considering business needs
  • Acted as the Clinical Service’s department lead on NCQA Standards and responsible to identify potential issues in Clinical Services and Prior Authorization department processes
  • Previously responsible to support NCQA and CMS audits, leading a team to provide accurate Clinical Services and Prior Authorization supporting documents
  • Collaborated with health plan audit teams to provide support for NCQA audits with minimal deficiencies identified
Clinical Pharmacist, Prior Authorization, 04/2000 - 01/2008
Prescription Solutions City, STATE,

Rendered coverage determinations on Medicare, Medicaid, and Commercial line of business based on clinical criteria and plan benefit design.

  • Streamlined department operation by programming relevant clinical questions/decisions trees into Prior Authorization System for Customer Service Agents to gather the required clinical information on their first interaction with Providers resulting in more efficient and accurate reviews.
  • Performed monthly IRR audits on Prior Authorization cases to ensure consistency among reviewing pharmacists.
  • Communicated with Clinical Services and Client Management teams to simplify clinical guidelines for ease of implementation.
Bachelor of Science: Chemistry, Expected in
University of California, Irvine - Irvine, CA,
: Doctor of Pharmacy, Expected in 05/1999
University of The Pacific, School of Pharmacy - Stockton, CA,

California Board of Pharmacy, Active and Clear, License RPH 51461

Farsi :
Native or Bilingual:
Negotiated :

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School Attended

  • University of California, Irvine
  • University of The Pacific, School of Pharmacy

Job Titles Held:

  • Pharmacy Manager, Medicare Part D Appeals
  • Clinical Pharmacist, Pharmacy Prior Authorization
  • Manager, Clinical Services Quality and Compliance
  • Clinical Pharmacist, Prior Authorization


  • Bachelor of Science

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