•Review existing logic in claims processing for potential areas for improvement; analyze claims edits and FWA opportunities; identify errors that could be costly to HPS. Reviewed transition overrides, quantity over time edits, and protected class logic to contribute to savings trends for high cost specialty drugs. •Create a VSR with collaboration from benefits and clinical to correct and simplify the day supply logic (including extended and restricted day supply) for specialty drugs for commercial plans.•Develop a process with CPO to identify duplicate therapy claims that occur on both medical and pharmacy to initiate recoupment with medical providers.•Create a governance program around Specialty drug data including managing the creation and communication of Specialty definitions and drug lists (including Limited Distribution drugs, medical PA products, and mandatory specialty). Including the development of a VSR to design a Specialty data warehouse within our Centralized Formulary system.•Build a 340B database to compare our contracted entities with the HRSA list for our potential savings or contracting opportunities.•Research and document the existing pharmacy benefit logic for the Commercial Specialty benefits; including mapping out the iterations of historical data, reviewing the claims processing logic, and work on developing a new member friendly benefit design that also drives more utilization to Humana Pharmacies. •Drive a pilot of a Designated Specialty Network experience for Home office members including coordination with HSP to create custom drug list to drive point of sale and the web design, benefits, and networks teams to create an accurate member experience

Implement solutions to control logistical issues around coordination of benefits for the Medicaid population.Initiate project development, create VSRs, and coordinate with partners and stakeholders. Monitor project progress, testing, and production validation.Monitor processes to ensure that improvements are effective and asses for additional areas of opportunity for streamlining through claims analysis (looking for inappropriate payment by Humana as primary or secondary for Medicaid membership).Report to leadership the progress of financial impact of the implemented processes; including the collection of subrogation efforts both internally and through our external vendor.Review the end to end processes that exist with the entire CTO team to identify areas and processes that need to be changed or updated for efficiency.

• Streamline, improve, and document processes as they relate to the ePrescribing functionality both internally as well as with external vendors and partners.• Build and maintain working relationships with direct connect EMRs. Including monitoring the accuracy of Humana’s data on the EMR sites, organizing and running weekly meetings, tracking progress on action items, and contract review.• Work to create formulary pay and deny report parameters for use in early issue detection (relying on previous formulary knowledge).• Collaborate on ‘IntelligentRx” projects as they relate to the direct connect and claims processor. Provide input on design, functionality, and testing parameters on:o ePAo Real-time benefit inquiryo Medication Adherenceo Point of Prescribe

• Serve as a SME for the Catamaran (CTRx) claims processing system (training of new associates and other business area SME’s, and assigning access).• Compile, analyze, and report audit data and results for CMS, Acumen, ATTAC, CTRx, and the Plan Sponsor as well as serve as a SME on CMS audits.• Ensure the integrity of the CTRx production claims processing system by monitoring the quality of data loaded into the system as well as the processing rules, logic and edits. Specifically focused on formulary, LTC short cycle, home infusion, transition, and pro-ration logic via monitoring of CMS guidance and memos. • Research, track, and identify (including root cause and potential solutions) any issues within CTRx’s claims processing system.• Develop processes and work instructions for the auditing and monitoring of LTI reporting, reprocessing, transition letters, and EOBs, Create and oversee the daily claims audits for early issue detection.• Prepare a client facing monthly slide-deck to report out plan health & monthly metrics for the Plan Sponsor.• Analyze all software (system) and data changes to identify business areas impacted and ensure all changes are tested; including validation of CTRx testing plans and testing results.

• Oversee the Argus adjudication Re-engineering projects; including streamlining the process to sync Humana data with Argus data.• Create and implement new processes and policies for the build and maintenance of formulary data in the re-engineered system with claims processor.• Maintain and oversee completion of updates to the internal data repository with multiple business partners, including IT, clinical, benefits, ePrescribing, and web.• Approve and disseminate changes submitted from clinical, as well as track the completion of the data for SOX audit requirements and lead and manage custom client audits for Formulary Operations.• Coordinate training of new associates and workload of Formulary Operations.• Build, implement and manage custom formularies as well as custom group data requests, Marketing material creation and ad hoc reporting.

• Maintain Commercial and Part D Drug Lists with external claims processor (Argus); including tiers, prior authorizations, step therapies, and quantity limits updates and corrections.• Daily Access use including creation and maintenance of queries, reports, tables, and forms.• Research and analysis of FDB drug data as it relates to the Drug List and member utilization.• Maintain and create printable drug guides for Commercial Drug Lists.• Create Policy and Procedures documenting Formulary Operations processes; as well as, creating new processes to increase productivity and accuracy.• Build and maintain new customized Drug Lists with external claims processor.• Train and manage workload of team of five associates.

• Draft required Summary Plan Documents for new and renewing self-funded clients.• Review, revise and/or approve Summary Plan Document drafts received from self-funded clients. • Manage multiple accounts with attention given to both ensuring accuracy and meeting tight deadlines. • Work closely with Account Implementation Managers, Sales, Contract Systems, Operations, Clients and other Analysts. • Train new hires.• Create process work flow documents for the Plan Management Agreements.• Redraft, update and maintain Plan Management Agreement documents.• Create and implement a changes tracking tool for use by all contract analysts.

Maintain database, tracking all incoming proposals, Geo Access requests, and finance requests.Review and interpret all requests to determine if all necessary data is provided for completion and work with both internal and external requestors to obtain the correct data.Create and balance month end reports outlining workflow and productivity.Determine and report year end sales close ratios.

Prepare Geographic Accessibility reports and Network Geographic Analysis through analysis and manipulation of census data.Complete service area ZIP Code files, service area verifications and provider disruption reports.Assist Proposal Analysts, Sales and consultants with completion of proposal documents in connection with GeoAccess, disruption, service area zip codes, and network composition.Assist in training of the Network Geographic Analysis and GeoNetworks programs for my team.

Research and develop information to include in sales proposals for national and local governments and companies.Manage sales proposal life cycle under customer driven deadlines.Team with sales leader, consultants, and management on all levels of the proposal process, from front-end issues, to researching information and problem solving.Research, author, and update proposal responses housed in the knowledge base system used by the proposal and sales departments.Complete, proofread, and format final proposal documents.Team leader, including the review of proposals of my team for accuracy, content, punctuation, and grammar.