David Maples Email & Phone Number

Salt Lake City Metropolitan Area

Manage all aspects of Caribou’s Pharmacy Plan Benefit Audit team. Responsible for planning and overseeing execution of all PBM Pre-implementation, Post-implementation, and Annual Plan Benefit audits on behalf of Fortune 500 companies. Also responsible for managing and enforcing quality control. Team is responsible for translating the plan benefit data in.

Responsible for development and maintenance of pharmacy the SUNRx 340B pharmacy network. Responsible for solicitation and renewal of network pharmacy contracts.

Supervised all facets of the Catalyst Rx FWA program personnel, directing caseload and reviews investigations for accuracy and timeliness. Provided overseeing, logging, tracking and reporting of all FWA incidences and assigning all cases for investigation.Conducted on-going evaluation of FWA program and evaluating opportunities to improve processes.

Gathered documentation in preparation of audits for Medicare Part D audits initiated internally by Compliance or externally by Catalyst Rx clients or federal agencies. Performed internal audits within Medicare Services, ensured documentation and controls were appropriate and aligned with CMS guidelines. Audits included Prompt Pay, Coverage Determination.

Responsible for creating and maintaining positive relationships between CVS Caremark and multiple retail pharmacy groups/chains/PSAOs.Field and assist in the resolution of multiple types of pharmacy inquiries including reimbursement inquiries, financial adjustments, claim adjudication and data analysis.Assist in marketing new CVS Caremark programs to.

Managed all aspects of RxAmerica's pharmacy audits, technical audits, benefit design verification, and Medicare Part D policy and procedure audits. Created and implemented policies and proceduresWorked with external audit firms to verify claim adjudication accuracy in accordance with clients benefit design set up. Increased on-site pharmacy audits over.

Supervised RxAmerica's desktop and on-site pharmacy audits and benefit design verification teams (10 direct reports).Streamlined reporting process of final pharmacy audit reports. Automated pre-audit communications to pharmacy contacts.Developed tracking database for on-site audit recoveries.Performed impact analyses for benefit design verification and.

Identified errors in claim adjudication through pharmacy desktop audits and communicated with pharmacies to correct errors.Performed on-site audits to targeted pharmacies to ensure compliance with claim submission.Identified pharmacy fraud and reported findings to the appropriate parties.Reviewed system change documents and ensured accuracy of changes to.

B.S., Information Systems

A.S., Business

A.S., Accounting