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 preparation for the pharmacy audit system, Caribou Rx (CRx), analyzing and interpreting audit output, and making recommendations where exposure is identified. Interfaces with clients and their PBMs to reconcile discrepancies and confirm payment errors.

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, outcomes and communications. Communicated FWA issues to management and Clients with the support of Analysts. Worked with IT and Clinical to identify proactive analytics to combat FWA Worked with Legal and Compliance departments to draft corrective action plans as requested by the analysts. Monitor the implementation of the CAPs and assuring that the result of the CAPs achieve the desired end result.

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, Excluded Provider, Transition Fills and EOB MailingsWorked with Legal and Compliance departments to draft corrective action plans (CAPs) as requested by the auditors and clients. Monitored the implementation of the CAPs and assuring that the result of the CAPs achieved the desired end result. Updated policies and procedures for various Medicare Part D functions. Developed process improvements for audit findingsAided in the development of Fraud, Waste and Abuse program documentation Aided in the development of effective Fraud, Waste and Abuse reporting for internal review and for clients.

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 pharmacy groups; including new network offerings, Caremark consumer card programs, Medicare Part D, pharmacy audit and contractual compliance issues.Train and educate chain/PSAO directors and vice presidents of pharmacy on Caremark Retail Services programs. Create, analyze and present performance reports to pharmacy contacts at trade shows and annual conferences.Create new applications and processes to reduce inquiry research and resolution time.

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 300% and increased recoveries of desktop pharmacy audits to over $4 million in 2009.Managed workload and resources for 25 direct reports.Maintained and enhanced audit recoupment and reporting databases for pharmacy on-site and desktop audits.Completed special projects including drug utilization, margin, new and current plan analysis.Created and presented quarterly audit findings reports and analyses to new and existing clients.Created and provided monthly trainings to enhance employee skill set.

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 created impact reports for internal and external partners. Created and presented audit presentations to internal and external clients.Submitted and reviewed test claims for adjudication accuracy.

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 formularies, co-pays, contract rates and other plan design changes utilizing Microsoft Access and SQL.Performed reimbursement calculations for coding inaccuracies and worked with internal teams to resolve issues.Created reporting measures to track client performance guarantees.

B.S., Information Systems

A.S., Business

A.S., Accounting