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Jessica Claire
  • Montgomery Street, San Francisco, CA 94105
  • Home: (555) 432-1000
  • Cell:
  • resumesample@example.com
Professional Summary

Versatile accomplished healthcare professional with superior communication skills. Rapidly promoted for quality excellence. Innovative pharmaceutical benefit expert focused on high-quality results and client satisfaction. Strong ability to undertake and manage all phases of plan implementation and maintenance. Proven foresight in balancing and prioritizing client requirements against benefit requests and CMS regulations. Well-versed in building positive relationships with customers and other stakeholders. Strong requirements gathering, scope development and inventory coordination abilities. Skilled at overseeing complex, high-value technical projects with excellent planning competencies.

Skills
  • Risk mitigation planning
  • Quality assurance
  • Documentation Management
  • Relationship development
  • Supervision
  • Team management
  • Reporting template development
  • Customer service
  • Operational improvement
  • MS Office
  • Process improvement
  • Problem resolution
  • Project organization
  • Team building
  • Communications
  • Regulatory Compliance
  • SQL
  • AS400
  • EZTEST
  • Claim Adjudication
  • CMS Guidance (3,4,13,18)
  • ICD 9 Codes
  • CPT Codes
  • Prior Authorization
Work History
Project Management Specialist, 11/2016 to Current
Luk IncWinsted, CT,
  • Gathered requirements, defined scopes, allocated resources and established schedules meeting or exceeding project demands
  • Managed minimum of 10 projects each year while maintaining adherence to budget, schedule and scope requirements
  • Investigated and corrected or escalated project problems
  • Adjusted project plans to account for dynamic targets, staffing changes and operational specifications
  • Built and utilized reporting systems to keep customers and management in loop with latest information
  • Resolved problems, improved operations and provided exceptional client support
  • Responsible for all aspects of Medicare Part D Member Correspondence, including, but not limited to: creation and maintenance of all member communications for Medicare Part D beneficiaries, and monitoring (daily, weekly, monthly) of Medicare Part D Print Operations
  • Creates templates for Centers for Medicare & Medicaid Services (CMS) Model and non-Model member letters
  • Thoroughly understand the yearly Medicare Communications and Marketing Guidelines
  • Managed quality assurance program, including on-site evaluations, internal audits and customer surveys
Quality Assurance Lead, 01/2014 to 11/2016
FingerpaintPhoenix, AZ,
  • Analyzed quality management system metrics to identify trends, lead improvement projects and prepare third-party inspections and audits
  • Investigated variances, performed root-cause analysis and documented corrective actions to resolve complications
  • Established new and improved QA processes by developing test processes, test cases and assigning and executing tests
  • Used SQL to validate test results and recommend corrective actions
  • Wrote, reviewed and approved documents to preserve quality assurance
  • Designed test bed coverage to cover all necessary scenarios (positive and negative) as per the client benefit matrix while ensuring no other benefit changes were unintentionally implemented
  • Lead and managed quality reviews for monthly utilization management and formulary updates for custom Medicare clients working also with our internal Medical Affairs team of pharmacists
  • While in this position was also designated as the backup Manager in which assumed full managerial duties in the absence of the serving manager, in addition to my own role and responsibilities. My Managerial responsibilities and tasks were:
    • Coaching our team to improve quality.
    • Provided all deliverable for our matrix and quota.
    • Reporting up and delegating down
  • 44% decrease in client reported issues
  • 99.8% of all request were completed on time, from 87% in 2015
Clinical Support Specialist, 01/2013 to 01/2014
Baptist Health South FloridaTavernier, FL,
  • Monitored progress and documented any patient health status changes, keeping healthcare team updated
  • Maintained clean, safe and well-organized patient environment
  • Supervised daily activities and provided assistance when needed
  • Identified eligible patients for the case management review and worked with the nursing team to assign each patient to one of the 150 nurse practitioners based on expertise and workload
  • Coordinated with the hospital staff to obtain patient discharge details and schedules
  • Monitored patient drug adherence post hospitalization and alerted the assigned nurse practitioner of any drug compliance issues
Pharmacy Services Specialist, 01/2010 to 01/2013
CignaCity, STATE,
  • Interpreted prescriptions from healthcare providers to properly dispense medications and health products
  • Processed Prior Authorizations for medications via calls, faxes, and email to/from patients, physicians and pharmacists while ensuring a high level of accuracy and maximizing productivity
  • Contacted patients, pharmacists and doctors' offices to resolve claims issues as well as explain benefits and co-pay structures
  • Met established quality standards by following all guidelines for Medicare patients from CMS, and providing excellent customer service with thorough documentation of each call
Education
High School Diploma: , Expected in 05/2007
Mountain Pointe High School - Phoenix, AZ,
GPA:

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Resume Overview

School Attended

  • Mountain Pointe High School

Job Titles Held:

  • Project Management Specialist
  • Quality Assurance Lead
  • Clinical Support Specialist
  • Pharmacy Services Specialist

Degrees

  • High School Diploma

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