Irvin Sotelo, Bba,Is Email & Phone Number

Morristown, New Jersery, Us

Morristown, New Jersery, Us

Long Beach, California, Us

Under direction, supervise subordinate staff, volunteers, and program participants.Install, modify, and repair computer hardware and software for multiple community centers.Run diagnostic programs to solve computer problems.Resolve technical problems with Local Area Network (LAN), Wide Area Networks (WAN), and othersystems.Install computer peripherals for users.Provide technical assistance and support for staff, and participants for issues related to computersystems, software, and hardware.Develop, plan, market, and coordinate programs for youth consisting of after-school recreationalprograms, youth sports, workshops, specialty events, tournaments, classes, fitness programs, andexcursionsPrepare documents and written reports and correspondence including monthly program calendars and incident reports.

Morristown, Nj, Us

Morristown, Nj, Us

Morristown, Nj, Us

Identify potential issues, project charge, and scope. Leads efforts to identify best practices. Identify impacted parties, business partners, and resources required. Develops and designs processes and systems that support business needs. Designs methods for integrating function and process. Conducts cost/benefit analyses. Builds support for business change throughout the business unit.

Indianapolis, Indiana, Us

Identify potential issues, project charge, and scope. Leads efforts to identify best practices. Identify impacted parties, business partners, and resources required. Develops and designs processes and systems that support business needs. Designs methods for integrating function and process. Conducts cost/benefit analyses. Builds support for business change throughout the business unit.

Long Beach, California , Us

Ensure regulatory compliance with respect to SCAN’s pharmacy network.Oversee accuracy of the pharmacy content on SCAN website and Medicare.gov website.Ensures Annual Enrollment Period (AEP) readiness and assists in training of other departments.Oversee accurate benefits/formulary/transition policy set up for all business lines and ensures year-round CMS Program Audit readiness in the area of formulary and benefits administration.Review and ensures accuracy of the Pharmacy Benefits for the annual BID submission to CMS.Provide support during CMS Regulatory Audits; e.g., CMS Program Audit, Transition Monitoring Program Analysis, Formulary Administration Analysis, Marketed versus Approved (MvA) formulary review analysis, etc.Prepare benefits/formulary analysis reports of other Medicare Part D Plans vs. SCAN to ensure SCAN’s pharmacy benefits and formulary meets the industry standard.Develop, implements, and maintains department’s standard operating procedures to ensure ongoing compliance.Collaborate with other SCAN departments: Compliance, Marketing, Digital, HCI, Product, and Member Services to support the achievement of team’s goals.Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching and counseling employees; initiating, coordinating, and enforcing systems, policies, and proceduresResolve issues and monitors results of daily staff activities, keeping management informed of key issues and problems as encountered.Maintain staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; developing personal growth opportunities.Instill a culture of continuous process improvement, efficiency, collaboration, operational excellence and compliance amongst team.Maintain current knowledge of Medicare Part D regulations by participating in CMS calls and reading released guidance and implementing changes to maintain compliance.

Long Beach, California , Us

Map and maintain group pharmacy benefits for all business lines to ensure accurate system set up and ongoing administration. Ensure benefits and transition policy are set up and adjudicating correctly by reviewing daily rejected claims report, daily transition rejected claim report, daily transition letter turn-around-time report, by performing testing on monthly and annual basis and by reporting errors to/resolving errors with the PBM. Update detailed benefit information in the member pharmacy marketing materials. Ensure materials are accurate and completed by provided deadlines and in accordance with CMS requirements. Update and maintain formulary changes. Ensure CMS formulary compliance by submitting Formulary/ Utilization Management/ Supplemental files to CMS. Review accuracy of the Pharmacy Benefits for the annual BID submission to CMS. Educate pharmacy department and other departments about benefit changes for the upcoming year. Update and maintain pharmacy content on the website for all business lines, to ensure that it remains current and accurate. Serve as Pharmacy Benefits Expert to the Pharmacy team and other departments. Interact daily with PBM representatives. Contribute to team effort by accomplishing related results as needed

Us

Acted as the liaison between the company and the client. Collaborated with the sales and the customer service department. Interacted with network and eligibility departments to resolve prescription issues.Translated codes for various departments. Maintained member’s prescription lists. Supported expansion of the Specialty Program.Coordinated and lead efforts to resolve client service issues with other departments. Deployed enhanced reporting packages. Ensured SOX compliance on Protrak tickets. Implemented CMA.

Us

Maintained accurate records of audit results. Identified patterns of errors made by claims personnel. Recommended procedures needed for training and coordinated with management. Assisted in the development of claims policies and procedures. Ensured that internal operations were in compliance and consistent with new developments, regulations,record keeping and reporting requirements. Assisted in the preparation of audits for internal and external auditors. Participated in interdepartmental meetings in order to support integrated projects. Supported the claims department in planning, analysis and troubleshooting capacities. Maintained ongoing communication and effective working relationship with peers, as well as with management. Build lasting rapport and cooperation and encourage peers to offer ideas and input. Performed other claims, auditing and technical duties as assigned by management.

Us

Deliver/facilitate training: Delivered new hire and incumbent job specific training using innovative methods that increase retention and enhance cost effectiveness. Delivered ongoing refresher training based on development needs. Measured and tracked pre and post training performance. Tracked completed training.Provide training feedback: Audited trainee work. Reviewed audits with trainees and make suggestions for process improvements. Coordinated and reported trainee audit findings and provide recommendations to the management team on additional training needsTraining Development: Reviewed and updated training materials as approved. Participated in departmental meetings to update the staff on changes. Assisted in developing training materials as needed. Acted as aresource to others as directed

Us

Assisted the prescription claims department by processing between 80-100 claims per day. Verified member demographics. Tracked daily processed claims. Troubleshooted issues, using a variety of computer programs such as the AS400.

Us

Responded to incoming calls from our customers on issues related to benefit eligibility questions and prescription status inquiries Guided and educated callers on their prescription benefits, use of plan, formulary, premiums and status of orders and claims or inquiries Asked appropriate questions and listen actively while documenting required information in computer systems Identified issues and communicate solutions and steps to customers, pharmacies and physicians with prescription orders and reorders Made outbound calls to customers on prescription orders and payment issues Researched complex issues pertaining to member prescription and/or pharmacy benefits across multiple databases which required fluency in computer navigation and toggling while confidently and compassionately engaging with the caller

Bachelor Of Business Administration (Bba), Computer And Information Sciences And Support Services

Associate Of Science (As), Business Administration And Management, General