Jaime D. Rodriguez Email & Phone Number

Remote

• ANALYSIS AND COMMUNICATION: Effectively collaborate with the team to compile medical notes (disease state, drug treatment history, and current drug plan) from the provider and patient in support of the prior authorization request. Review the request against the insurance policy decision tree for approval if compliance is achieved. Perform outreach for additional prior authorization follow-up information and as needed support the clinical request from high-touch clients with any changes. Achieved 100% on NPS surveys.• ORGANIZATION AND RESOURCEFUL: Promptly follow updates to OptumRx policy and operational procedures to prep, review and approve or deny requests for a prescription prior authorization and/or appeal. Ensure prescription prior authorization requirements are communicated to the patient/provider along with the clinical reason. Diligently troubleshoot or problem-solve any incomplete tasks assigned based on the need for business operations by phone, email, and ticketing software.• TRAINING / MENTORING: Assisted new pharmacy technicians into the high-touch client team for appeals packaging by providing experience on clients' requirements with the redetermination level appeals process. • COORDINATION: Multitasked workflow process if patient, provider, and dispensing pharmacy contacted OptumRx prior authorization/appeals department by insurance plan policy. Support communications and collaborate with the high-touch team to finalize updated clinical reporting to prior authorization and appeal requests to clinicians. Achieved 99.5% quality call audit review.

Baltimore, Maryland, United States

• DATA COLLECTION AND ANALYSIS: Support pharmacy with data entry reports and inform the Pharmacist in Charge of changes affecting processes and software, including Intercom Plus, SIMS, StoreNet, SORA and SR2/Asembia; report to pharmacy staff daily shipment to patients and analyze trends. Achieved URAC accreditation in 2018 for specialty pharmacy passing a score of 99%.• NEW STAFF TRAINING/ORIENTATION: Ensure employees complete mandatory training on Walgreens Learning and Talent Management Portal when hired and whenever policies or procedures change. Train and mentor new pharmacy technicians, rotational pharmacy interns, and new pharmacists in the Specialty Pharmacy business to comply with URAC accreditation standards. Created specialty pharmacy materials to train new employees on company policies and procedures.• WORKFLOW EVALUATION, ANALYSIS, AND COORDINATION: Review/audit reports regularly and use analysis to assign tasks to pharmacy technicians according to each employee’s knowledge, skill level, speed, and accuracy. Reports include Reserved/Outstanding Report; Deleted Aged Rx; Excess Inventory and Other Key Performance Indicators; Bin Reconciliation; Perform periodic audits to comply with URAC Specialty Pharmacy accreditation standards. Recommended Drug Location. Full Pharmacy Drug Inventory. Accomplished a reduction in insurance audit claims to 0% for 2016.• INSURANCE: Follow URAC guidelines to assure post-audit compliance with all prescriptions fulfilled at the pharmacy. Provide exceptional customer service in filling orders. Contact customers’ insurance carriers and Medicare as well as their care providers to fill prescription orders and obtain proper billing information. Communicate with customers concerning order status, billing information, availability, and delivery of medications. Enter prior authorization data into CoverMyMeds.com with appropriate clinical notes and follow up with providers and staff to establish appropriate patient care.