Allison H. Email & Phone Number

San Juan, Puerto Rico

San Juan, Puerto Rico

Dayton, Ohio, United States

- Develop, recruit, retain, and manage compliance and oversight staff to ensure that pharmacy operational and strategic goals are met while maintaining compliance with company, state, federal and contractual requirements for all lines of business (LOB)- Oversee all pharmacy compliance and oversight auditing and monitoring activities performed and tracked by staff- Oversee development and approvals of all policies and procedures (P&P) and standard operating procedures (SOP) for the… Show more - Develop, recruit, retain, and manage compliance and oversight staff to ensure that pharmacy operational and strategic goals are met while maintaining compliance with company, state, federal and contractual requirements for all lines of business (LOB)- Oversee all pharmacy compliance and oversight auditing and monitoring activities performed and tracked by staff- Oversee development and approvals of all policies and procedures (P&P) and standard operating procedures (SOP) for the pharmacy department as performed and supported by staff- Oversee all compliance and oversight activity tracking developed, maintained and reported in the Pharmacy Compliance Dashboard- Oversee and ensure timely completion of all external compliance requirements- Oversee and coordinate compliance issues and regulatory reporting with CareSource Compliance and Regulatory Managers and ensure resolutions are implemented - Oversee the delegated and non-delegated aspects of the pharmacy processes and associated regulatory requirements- Responsible for NCQA Accreditation standards and readiness for the Pharmacy Department- Provide oversight and monitoring of delegated activities to ensure compliance with state and federal regulations - Partner with Market(s), Pharmacy personnel, and Vendor Management on vendor-related and pharmacy-related contractual issues, CAP management and performance guarantees Show less

Dayton, Ohio

- Liaison with functional area leads within Pharmacy, Accreditation, Regulatory, Compliance, Quality, and Pharmacy Benefit Manager (PBM) Account Management Team;- Lead, oversee, and participate with new vendor implementations;- Responsible for NCQA Accreditation standards and readiness for the Pharmacy Department; - Work directly with Pharmacy Benefit Manager (PBM) and internal Vendor Oversight teams on issue tracking, resolution and contract compliance;- Monitor overall… Show more - Liaison with functional area leads within Pharmacy, Accreditation, Regulatory, Compliance, Quality, and Pharmacy Benefit Manager (PBM) Account Management Team;- Lead, oversee, and participate with new vendor implementations;- Responsible for NCQA Accreditation standards and readiness for the Pharmacy Department; - Work directly with Pharmacy Benefit Manager (PBM) and internal Vendor Oversight teams on issue tracking, resolution and contract compliance;- Monitor overall contract performance for the CVS and Outcomes contracts to ensure SLAs are being met, and initiating PIPs or CAPs as needed;- Coordinate internal and external audits with CareSource Regualtory, Compliance, and Vendor management teams;- Monitor, assess and report on corporate compliance with market, business, state, and federal requirements;- Develop monitoring and oversight program for non-Medicare lines of business;- Design/coordinate operational quality checks;- Cultivate, develop, and manage market director relationships- Ensure operational effectiveness by assisting in strategic and business planning, including identifying and implementing initiatives Show less

Florida

- Act as an internal resource for the implementation of regulatory and contract interpretations. - Provide objective and professional evaluations of the organizations operational policies and procedures to ensure regulatory compliance. - Maintain accurate historical records and comprehensive documentation of activities ensuring documents are compiled as needed to successfully meet requirements of governmental agencies and stored according to established record retention policies. -… Show more - Act as an internal resource for the implementation of regulatory and contract interpretations. - Provide objective and professional evaluations of the organizations operational policies and procedures to ensure regulatory compliance. - Maintain accurate historical records and comprehensive documentation of activities ensuring documents are compiled as needed to successfully meet requirements of governmental agencies and stored according to established record retention policies. - Build and maintain a positive relationships with external governing bodies including. but not limited to. CMS Central and Regional Offices as well as the various departments within the Office of Insurance Regulations. - Collaborate with other departments to research and resolve formal CMS beneficiary complaints. - Monitor, research and disseminate applicable regulatory and business requirements, to ensure timely implementation of any new Medicare laws, regulations, and contractual requirements. Special attention should be paid to email correspondence generated by the Centers for Medicare & Medicaid (CMS) through the HPMS system allowing for a timely response to and/or implementation of all notices. - Participate in external and internal audits related to regulatory and contractual compliance, effectively communicating Health First Health Plans’ position to regulators. - Prepare audit/data validation requests from Centers for Medicare & Medicaid Services. - Coordinate annual Bid requirements to ensure financial goals are met. Show less

- Developed and maintained objective scoring methodology for monitoring of Pharmacy Prior Authorization and pharmacy claim process. Monitoring activities included audits of intake, prior authorizations, eligibility, and system configuration;- Provided feedback to team members to reduce errors and improve process performance; - Oversaw and conducted new hire training materials for Pharmacy Benefit & System Specialists; - Participate in Stars, Gallup and Goals for the Pharmacy… Show more - Developed and maintained objective scoring methodology for monitoring of Pharmacy Prior Authorization and pharmacy claim process. Monitoring activities included audits of intake, prior authorizations, eligibility, and system configuration;- Provided feedback to team members to reduce errors and improve process performance; - Oversaw and conducted new hire training materials for Pharmacy Benefit & System Specialists; - Participate in Stars, Gallup and Goals for the Pharmacy Department; - Subject matter expert resource to team members and management staff; - Facilitate pharmacy technician meetings in conjunction with management; - Monitored and tracked agreed upon performance guarantees with the pharmacy benefits manager (PBM);- Supported health plan audits and compliance activities. Show less

Provide superior quality, competitive value and outstanding service by managing the HFHP pharmacy commercial and Medicare benefit. This role included:- Liaison between clinical operations, administrative operations and benefit design. - Operate, maintain, and assist the designing of the Pharmacy system software;- Subject matter expert for the plan's pharmacy benefit;- Oversaw the prior authorization workflow and ensured compliance with the state laws, regulations, and NCQA… Show more Provide superior quality, competitive value and outstanding service by managing the HFHP pharmacy commercial and Medicare benefit. This role included:- Liaison between clinical operations, administrative operations and benefit design. - Operate, maintain, and assist the designing of the Pharmacy system software;- Subject matter expert for the plan's pharmacy benefit;- Oversaw the prior authorization workflow and ensured compliance with the state laws, regulations, and NCQA standards. Show less

Insurance Verifier II- Interpret prescription insurance rejections;- Facilitate clinical prior authorizations;- Navigate commercial and government payer benefit information. Celgene Specialist - Process and facilitate time sensitive authorizations for all Celgene products; - Initiate communication with physicians’ offices regarding Celgene protocol;- Serve as liaison between the Celgene and Kroger Specialty Pharmacy (formerlyAxium Healthcare Pharmacy).

Primary responsibilities included receiving prescription orders, count and prepare medications, and prepare insuranceclaims. I also maintained and updated patient profiles, effectively communicated with physician offices and insurance companies as well as assisted with new employee training. During my career with Kroger I also obtained my certification through the PTCB and became a “Phase IV” CPhT that included additional responsibilities such as educate and instruct newly diagnosed… Show more Primary responsibilities included receiving prescription orders, count and prepare medications, and prepare insuranceclaims. I also maintained and updated patient profiles, effectively communicated with physician offices and insurance companies as well as assisted with new employee training. During my career with Kroger I also obtained my certification through the PTCB and became a “Phase IV” CPhT that included additional responsibilities such as educate and instruct newly diagnosed patients with their diabetic equipment. Show less

Primary responsibilities included customer service, patient education, and the promotion of positive communicationbetween clients and the medical staff. In addition to administrative duties I was also responsible for executing laboratory procedures, performing patient interviews, and obtaining patient vitals.

Primary responsibilities included obtaining patient histories, collect specimens, perform laboratory procedures, and assist in diagnostic, medical, and surgical procedures.

Bachelor Of Science (Bsc), Biology, General

Activities and Societies: BBB Biological Honor Society, Health Professions Club, Student Affiliates of the American Chemical Society.

High School Diploma