Anitha Stephen Email & Phone Number

Telecommuter

• Execute daily control reports, as well as completing data analysis and various clinical projects. • Prepare clear, medically concise case summaries for Medical Director review• Responsible for monitoring clinical coverage determination and appeals using Medicare and client specific requirements.• Knowledgeable in all aspects of coverage determination and appeals process and assist in meeting clients expectations regarding efficiency, services levels, privacy maintenance and quality decision-making.• Responsible for managing control team responsibilities as well as assisting with the review of medication exceptions, such as high cost, protected class drugs etc.• Work as part of the team to meet business unit objectives and escalate issues to Coverage determinations and Appeals management team as needed• Utilize critical thinking skills and superior problem solving capabilities to root cause audit findings and propose possible enterprise solutions. • Set up and manage group chats among team members weekly and answer any report related questions from techs/pharmacists of our team• Train fellow team members on certain topics when needed using conference call/screen share• Assist with reviewing existing control reports work instructions and provide feedback on necessary updates/additions

San Antonio, Texas Area

• Serves as point of contact to address clinical questions and ensures case decisions are based on clinical guidelines and established best practice processes• Assist with physician/member escalation phone calls• Maintains log of issues encountered, performs root cause analysis and submit reports to management to help improve quality and operational efficiency • Provides training on RxClaim, MedHOK and PeopleSafe platform for new hire pharmacists• Perform quality checks on completed cases for new hire pharmacists• Prepare productivity reports and participates in conference calls to provide feedback on pharmacists in training• Conducts performance evaluation and assessment quality (PEAQ) review for completed cases to ensure that the company criteria and Center of Medicare and Medicaid services (CMS) guidelines are applied consistently across the enterprise• Review re-open cases to verify accuracy and prepares cases for Medical Director review as required• Reviews redetermination cases (appeal) and assures requests are completed within turn-around-time and responded to in a competent manner according to established company criteria and CMS guidelines

San Antonio, Texas Area

• Utilizes RxClaim, MedHOK and PeopleSafe platforms to perform medication reviews for Medicare-Part D and EGWP beneficiaries and issues decision on initial coverage determinations and re-determinations for non-formulary, prior authorization, quantity limit, step therapy, and tier exception requests• Uses Medicare approved compendia, guidelines developed by health plan and patient history in making clinical decisions to ensure appropriate and cost effective prescription drug therapies are recommended • Identifies potential drug related problems by reviewing drug claims while completing prior authorizations and exception requests• Address inquiries from health care providers and plan members about drug coverage, counsels on potential cost effective therapeutic alternatives based on individual formulary coverage and structure in a call center environment• Assures that prior authorization requests are reviewed within turn-around-time and responded to in a competent manner according to established company criteria and CMS guidelines

• Facilitated communication between patients and health care professionals like pharmacists and the physicians to ensure that the needs of the patients are met• Created and maintained patient medication profiles, dispensed OTC and prescription drugs and ensured accuracy and efficiency of the retail pharmacy workflow • Accepted new prescriptions and refill orders from prescribers, transferred prescriptions in and out of pharmacy, counseled patients on drug therapy under supervision of a registered pharmacist