Emily Duchow Email & Phone Number

Pittsburgh, Pa

Oversee administrative and system processes as they relate to benefit plan design, implementation, training and maintenance for all UPMC Health Plan product lines. Serve as domain expert and technical resources to Claims department with regard to benefit administration functionality on transactional system. Conduct functional testing, managing reporting requirements and implementing new business applications.Responsibilities:• Administer, test and implement benefit plans on transactional systems.•Conduct transactional system functional enhancement testing, including electronic data interchange functions.•Coordinate and resolve system relates issues impacting claims adjudication. Maintain automated adjudication processes, identifies deficiencies and implements improvements.•Interface with customers by telephone, correspondence, and or in person to answer inquiries and resolve concerns to assure customer satisfaction.•Manage, update and maintain source data dictionaries as they related to benefit plan processes.•Serve as product and process expert to the Operations Division.•Train new and existing employees on departmental policies and procedures, maintain documentation of it.

Pittsburgh, Pa

Customer Service Analyst II for UPMC Health Plan Pharmacy Services. Acted as an advocate for all Health Plan employees by providing guidance, interpretation, and education on pharmacy benefit coverage, payments, claims processing, and various programs inquiries. Served as a mentor and coach to member service representatives across all lines of business: Medicaid, Medicare, HMO, PPO, Marketplace, TPA clients. Created training material for educational purposes across various departments. Worked independently on multiple special projects while simultaneously preforming regular job duties. Promoted from CSA I to CSA II in this role.

Pittsburgh, Pa

Job functions included:•Provided customer service support to UPMC Health Plan's Department of Pharmacy Services. •Interacted with physicians, pharmacists, and members to obtain information pertinent to the decision-making process.•Explained Health Plan sponsored benefits, and assist with pharmacy claims processing functions.• Investigate and troubleshoot issues regarding pharmacy claims processing.• Worked on all aspects of the prior authorization process: receiving, reviewing, and evaluating for quality assurance when complete. • Completed special projects quickly and while simultaneously preforming other job fuctionsSpecial projects included:1) Appointment of Representative (AOR) followup:• As part of the coverage determination process, assisted with completion of AORs when a coverage determination was submitted on behalf of a member.• Strictly adhered to the timeframe and guidlelines set in place by CMS.• Outreached to members to explain the AOR process and answer any questions regarding their spouse/parent/child's medications and benefit information. • Outreached to providers to determine course of action and to offer alternatives to medications not covered by members' insurance. 2) Need for more information (NMI) requests:• As part of the prior authorization process, outreached to providers to gather necessary personal health information so that UPMC could render decision on medication coverage. • Strictly adhered to the timeframe and guidelines set in place by CMS.• Worked closely with clinical pharmacists to determine alternative dosing regimens and formulary alternatives to suggest to providers.• Utilized extensive knowledge on drug coverage across all lines of business: Commercial, Marketplace, Medicaid, Medicare, TPA clients.

Cranberry Township, Pa

Associate'S Degree, Business Administration And Management, General, 3.0

Education record