Andrea Cooling Email & Phone Number

Chattanooga, Tn, Us

Chattanooga, Tennessee, United States

Chattanooga, Tn

Promoted multiple times with increasing levels of leadership responsibility. Directed a team of five managers dedicated to maintaining and growing existing relationships with 15 pharmacy operations analysts. Managed and developed ongoing relationships with a Pharmacy Benefit Manager (PBM) (Express Scripts), a medical PBM (MagellanRX), and the Specialty Pharmacy Network, with a focus on the administration of contracts, audits, pricing, and delegate oversight. ➣ Instrumental in implementing MagellanRX as a new medical PBM to perform prior authorizations for provider administered specialty medications. ➣ Pioneered the development and roll-out of a new oversight program for contracted vendors to ensure adherence to contracts while implementing reporting processes.➣ Owned the BCBS relationship with Express Scripts, the company’s largest PBM, while providing input on large, complex RFPs as a trusted SME.➣ Led and developed pharmacy reporting and analytics processes in conjunction with medical informatics, actuary, finance, and Express Scripts. ➣ Hired, trained, coached, and evaluated the performance of respective network coordinators. ➣ Primary driver of the timeline and successful execution of BCBST’s pharmacy benefit programs implemented by the PBM. ➣ Drove operational functions while collaborating with pharmacy, medical, and network leaders to ensure operational and clinical services meet the needs of the members, providers, and customers.

Chattanooga, Tn

Charged with the daily management of the PBM contract comprised of over $1B in annual drug spend, $2.5M in performance guarantees, a $3.5M pharmacy management fund, and the oversight of networks, rebates, pricing, and audits. Accountable for the Medicare Part D Prescription Drug Program (PDP) with Prime Therapeutics and BlueCross BlueShield of Alabama. Supervised a two-person analyst team. ➣ Facilitated and led strategic meetings with the PBM account team, marketing, commercial operations, MedAdvantage operations, business engineering, and information systems.➣ Managed the contract and ongoing relationship with the external PBM partner, Express Scripts, for both commercial and the Medicare Part D lines of business. ➣ Designed, developed, and documented processes and workflows to support the PBM relationship and all operational and strategic pharmacy initiatives.➣ Led Medicare Part D audits as required by the Centers for Medicare and Medicaid Services (CMS).➣ Monitored and measured vendor performance to ensure short and long-term attainment of contractual, operational, financial, and service objectives.➣ Served as the pharmacy business owner for all delegate oversight and restricted data functions. ➣ Vital member of the PBM transition team for the BCBST move from Caremark to Express Scripts.

Chattanooga, Tn

Provided strategic direction, guidance, and daily support to a ten-person quality team consisting of configuration quality specialists and quality analysts. Teamed up with the marketing staff to ensure the quality and accuracy of large group benefit configurations; maintained group transmittals, holds, and files.➣ Conceptualized and executed a new Evidence of Coverage (EOC) Audit process for all self-funded accounts that included simulated claims testing.➣ Established and developed close relationships and communications with various business areas.

Chattanooga, Tn

Oversaw and managed a four-person team with full accountability for a $2.5M annual operating budget that included software development. Prioritized projects based on corporate requirements, industry demand, and budget constraints. Led contract negotiations related to system development and software licenses.➣ Championed the introduction and company-wide implementation of SalesLogix, the company’s first CRM; coordinated daily statewide support for 1,400+ SalesLogix and BlueWizard end users.➣ Worked closely with BCBST regional offices regarding internal processes to ensure SalesLogix efficiently met their needs; identified system modifications and customizations.➣ Maintained collaborative relationships with the internal IT department and the external vendor that provided SalesLogix and BlueWizard modifications and customizations.

Chattanooga, Tn

Directed day-to-day operations of multiple Riverbend Group Benefits Administrator departments and tasked with safeguarding the National Medicare Trust Fund. Charged with leading the hiring, training, development, and ongoing performance management of both clinical and non-clinical staff. Held full accountability for the following departments:➣ Medicare Medical Review staff of twelve registered nurses that reviewed medical records to verify billed charges and determined medical necessity and appropriateness of care.➣ Focused Medical Review staff of three data analysts that conducted daily data mining and analysis to identify aberrancies in provider claims, based on Medicare regulations.➣ Medicare Medical Appeals led in-depth reviews on denied benefits by validating original Medicare contract interpretation and subsequent benefits administration to substantiate the denial or to reverse it, based on Medicare regulations.➣ Medicare Secondary Payer staff tasked with maintaining strict adherence to Medicare regulations and preventing the overpayment of benefits when a second payer was involved. ➣ Medicare Subrogation included a staff attorney that worked to recover the overpayment of Medicare benefits due to another carrier’s primary liability.➣ Local Area Network consisted of the workgroup administrator that oversaw all software application development and external vendor engagement in support of the Medicare division supervisor.

Chattanooga, Tn

Chattanooga, Tn

Chattanooga, Tn

Chattanooga, Tn