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.
· 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
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.
Rendered coverage determinations on Medicare, Medicaid, and Commercial line of business based on clinical criteria and plan benefit design.
California Board of Pharmacy, Active and Clear, License RPH 51461
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