Responsible for the end-to-end contracting process including, contract strategy development and negotiation through to execution with an emphasis on complex, high profile negotiations. Develop, facilitate and implement provider negation strategies that support strategic and corporate goals. Responsible for the ongoing monitoring and management of contract terms including claims system configuration, contract oversight and adherence to all managed care health plan requirements. Provides support in the absence of a manger.

2022 _ Rhode Island Interscholastic League - Division 4 & R.I. State Champions

Ensure contractual and regulatory compliance as it relates to third party programs. Act as a liaison between internal departments and external contacts such as health plans, processors, pharmacy benefit managers (PBM), and governmental agencies. Additionally, facilitate the initiation and on-going maintenance of pharmacy system to ensure that CVS Health pharmacies are able to service and bill prescriptions for patients of third-party programs, where CVS Health is contracted and/or enrolled.

Responsible for identifying areas of enhancement for the process that CVS Health uses to adjudicate prescriptions claims with different Third-Party Payers. Research and coordinate projects to improve the adjudication process due to changes in law (Federal & State), industry and profit on state, regional and nationwide scale. Coordinate the NCPDP Version D.0 to VF6 updates with different key stakeholders that will be impacted by the change to ensure all are prepared. Lead research and developer for ideas submitted through the Colleague Connect platform in both the field and the store.

Responsible for the daily management of assigned 340B administrator(s), its active clients and/or contracted entities. The position requires the ability to interact with a wide variety of Covered Entity personnel, from Senior Management to operational staff. Duties include managing tasks, projects, and plans for various 340B covered entities (i.e. disproportionate share hospitals, federally qualified health centers) simultaneously, while meeting designated deadlines and standards. This position also includes extensive interactions with internal departments including Pharmacy & Field Operations, Accounts Receivable / Payable, Inventory.

Administrates FCHP authorization processes as outlined in Member Handbook/Evidence of Coverage for all products, in compliance with applicable NCQA standards and other state or federal regulatory requirements.Conducts case review of all risk issues regarding member authorizations, weighing interests of all customers, both internal and external.Approves authorizations by applying FCHP physician determined protocols, policies and procedures; authorizations not meeting protocol parameters are prepared for review, including direct contact with physician’s offices and physicians to obtain records and clinical information in support of the request.Works with team leaders, department managers, department chairs and/or medical director to resolve issues; formulate improvement measures and response to members; prepares written correspondence to members. Strictly adheres to department standards for completion of referral TAT and notifications target of 90% within 2 business days for service requests. Adheres to the department standards for phone abandonment rate. Accepts authorizations for FCHP members, screens for member eligibility and enters information into the FCHP core system. Answers claims/authorizations questions from members, providers and PCP offices. Project: Responsible for preparation of oral nutritional supplement requests. Obtain clinical, functional and psychosocial information regarding oral nutritional formula requests from the medical records on site, through electronic access, by telephone or by fax in a collaborative effort with other health care professionals, member and/or family.Acts as a liaison between providers, members/families, and FCHP.Clarify policies/procedures and member benefits regarding oral nutritional formula as needed.Ensures timeliness and coordination of healthcare services for oral nutritional formula requests.Refers prepared cases for oral nutritional formula requests to medical director review according to policy and procedure.