逗号简历

Tracked evidence submissions and feedback on policies and prioritized policy updates and played an active role in policy customization with external partners (PBMs).

Stayed close to UM and clinical content by performing UM reviews and supported clinical training and remediation.

Ensured processes and documentation are in place and in compliance with State, Federal, and NCQA requirements and provided support on regulatory audits and quality accreditation surveys, as needed.

Assessed clinical topics related to the resident’s care, reviewed the use of medication management and entered patient data into an Excel spreadsheet for analysis.

Conducted clinical reviews of medical data collected to perform prior authorization for specialty medications.

Ensured turnaround times and state regulations are being maintained and adhered to at all times for New York and Minnesota Medicaid benefits and trained newly hired pharmacists and assist with various clinical inquiries.

Answered clinical questions, collected appropriate medical data needed to perform clinical assessments, and reviewed as per the health plan/employer agreed on criteria within the designated service level agreements.

Responsible for support and input to clinical programs such as Health Management, Drug Utilization Review, Formulary development, and Prior Authorization programs to encourage appropriate, high-quality, cost-effective drug therapy.

Participated in the Coverage Determination (Certification, Prior Authorization, Medical Exception, Exception to Coverage, etc.) process by reviewing all requests which are not clearly approvable based on specified criteria.

Proficiently processed and dispensed written, oral and electronic prescriptions and conducted drug utilization reviews, drug interventions, and medication therapy management.

Directed operations to increase efficiency and reduce patient hold times and oversaw technicians' drug preparation and distribution to provide safe and efficient care for patients.

Participated in the development, administration, and implementation of a vaccination clinic, as well as cholesterol, diabetes, and bone density testing.