Quality Assurance Engineer

MEGAN TAYLOR

Roanoke, TX · 404-***-****

ad5n9q@r.postjobfree.com

Product Test Consultant; Quality Engineering & Assurance

EXPERIENCE

APRIL 2023 – PRESENT

QUALITY ASSURANCE ENGINEER, TATA CONSULTANCY SERVICES

Job Responsibilities:

• Conducts functional and UAT testing and technical analysis for RxClaims PBM software

• Uses business specifications and clinical UM requirements to translate pharmacy rules and processes into functional test cases.

• Uses professional skills and understanding of the pharmacy/PBM industry, including laws and regulations, to create relevant scenarios necessary for accurate test bed design, execution, and validation.

*Experience working on Commercial, Medicaid, Medicare, and EGWP plans

*Experience working for CVS client on clinical and benefit test cases for BCBSTN and BCBSMA

MAY 2018 – MARCH 2023

LEAD QUALITY ASSURANCE ENGINEER, cognizant technology solutions

Job Responsibilities:

• Conducts functional and UAT testing and technical analysis for RxClaims PBM software

• Uses business specifications and clinical UM requirements to translate pharmacy rules and processes into functional test cases.

• Uses professional skills and understanding of the pharmacy/PBM industry, including laws and regulations, to create relevant scenarios necessary for accurate test bed design, execution, and validation.

• Experience working both independently and collaboratively on all areas of testing pertaining to the CVS Anthem migration project including: Benefits, Clinical UM, Formulary, DUR, Claims, PA, Certification, and Model Office testing, in both pre- production, and production environments.

• Experience working on New Business Implementation Team (NBI) to conduct clinical benefits testing for CVS new business clients.

• Experience working on Formulary Management Systems Team (FMS) to conduct research and analysis for formulary migration.

• Experience working on EGWP Team, conducting clinical and benefit testing for group Medicare Advantage plans.

• Worked with CVS leadership on section 204 of the Consolidated Appropriations Act Prescription Drug Cost Report of 2021 (CAA RxDC) to gather, analyze, and submit required drug cost reports per CMS protocol

**Experience working on Commercial, Medicaid, Medicare, and EGWP plans

• Assures product consistency while adhering to strict delivery schedules, to expedite and ensure the seamless migration of large PBM clients and data.

Skills Used:

Microsoft Office, Sequel, Salesforce (SFDC), AS400, EzQuery, RxClaims, Sharepoint, WinSCP

OCTOBER 2017 – APRIL 2018

DATA VERIFICATION SPECIALIST, Cardinal Health

Job Responsibilities:

• Provide Accurate verification of customer insurance benefits obtained via phone or web

• verify most recent deductible, copay, coinsurance or out of pocket accumulations for each account in question

• Verification of coverage of supplies ordered• Verification of network participation with the customer's insurance plan

• Knowledge of financial processes, systems, controls, and work streams.

• Worked collaboratively in a finance environment coupled with strong internal controls.

• Understand service level goals and objectives when providing customer support.

• Respond to non-standard requests from vendors and customers.

• Possess strong organizational skills and prioritize getting the right things done.

• Audit claims as necessary per CMS guidelines/regulations and company SOP's

• Identify billing and coding discrepancies

Skills Used:

Microsoft Office, Emdeon (Change Healthcare), Availity, NaviNet, RGH, Insurance specific provider portals used for accessing real-time benefits authorization/claims adjudication, e.g., BCBS-Web Denis, Humana, Aetna, Coventry, UnitedHealth Care & its subsidiaries, Ambetter, Centene, Sunshine Health, Allwell, CMS, EmblemHealth, TennCare, Ky Passport, etc

AUGUST 2014– AUGUST 2017

PHARMACY FIELD AUDIT SPECIALIST, NorthStar HealthCare Consulting

Job Responsibilities:

• Review pharmacy claims for compliance with client policy and state or federal guidelines and laws.

• Knowledge of the PBM industry, formulary management, DUR clinical programs, pharmacy claims and managed care principles and practices.

• Perform retrospective claims review to identify program compliance.

• Identify suspected pharmacy fraud and abuse from claims data.

• Work closely with pharmacy audit personnel in conducting claims review.

• Work closely with the analytics support specialist to develop and provide reports for clients.

• Analyze trends in drug utilization patterns and costs.

• Work closely with Program Compliance team to develop, test, improve, and implement pharmacy audit programs.

• Provide insights and valuable contributions to the development of audit-based algorithms and scorecards.

• Detect data problems by executing computerized database queries.

• Provide information by collecting, analyzing, and summarizing data and trends.

• Enhance clinical data department and organization reputation by accepting ownership for accomplishing new and different requests.

• Recognize, summarize, and refer possible fraud related activities found within the pharmacy to appropriate government officials.

• Other duties as assigned by management.

Skills Used

Microsoft Office, RxClaims, PioneerRx, Intercom Plus, Surescripts, and other proprietary audit programs for the use of claims analysis, reimbursement, and reconciliation purposes.

APRIL 2014– AUGUST 2014

PBM HOSPICE ACCOUNT MANAGER, ProCare Rx

Job responsibilities:

•Provide daily and ongoing support for hospice administration.

• Assist pharmacies with claims adjudication errors and approve prior authorizations for hospice covered medication as needed.

• Perform pharmacy analysis assignments based on the specifications requested by client or department.

• Investigate and resolve claims disputes between hospice and contracted pharmacy, and submit error reports as needed.

• Investigate and submit MAC disputes based on contracted pharmacy rates, dispense dates, and pharmacy invoices.

• Provide formulary management for hospice plans based on patient disease state, client, administrative preference, CMS compliance, and clinical recommendation.

Skills Used:

The use of multiple proprietary software programs such as, eProcare, Admit24, DMW, CMW, RR, and ProcareRX, in conjunction with SugarCRM, and Microsoft Office.

JUNE 2013 – APRIL 2014

IMPLEMENTATION SPECIALIST, AlixaRx

Job responsibilities:

• Implement and provide support for pharmacy services and ADU (automated dispensing unit) Implementations as they relate to all aspects of medication management in nursing facilities.

• Serve as the primary resource for training long term care facility personnel.

• Evaluate implementation and support conversion form previous pharmacy to new pharmacy.

• Deliver coaching and feedback to implementation team members to assure optimal team performance.

• Complete medication cart audits with the utilization of Medication Administration Reports (MAR), and federal/state regulations.

• Create educational materials for the purpose of in-servicing nursing home staff and administration.

• Schedule and conduct in-services for nursing home staff and administration on topics related to Remote pharmacy operations, software upgrades, and ADU policies and procedures.

• Complete facility profile, technology and service assessment.

• Apply understanding and familiarity with pharmacy regulations to support successful ADU implementation.

• Coordinate the order and delivery of Med Carts with Operation Support Team.

• Complete acceptance criteria and related reports and test automated dispensing unit (ADU) prior to implementation.

Skills Used:

Microsoft Office, Docu Track, FrameworkLTC, proprietary software relating to ADU and remote pharmacyoperation

DECEMBER 2011– JUNE 2013

SENIOR CERTIFIED PHARMACY TECHNICIAN (CPHT), CVS Health

Job Responsibilities:

• Prepare and fill prescriptions.

• Perform data entry for hard-copy, facsimile, and electronic prescriptions.

• Bill insurance companies and resolve insurance related issues.

• Reconstitute medications.

• Maintain inventory and submit daily orders to suppliers.

• Communicate with prescribing physicians to verify new prescriptions and update existing refill requests.

• Pull and return out-of-date medications to appropriate vendors.

• Maintain customer relations and monitor patient prescription compliance.

• Internal and external audit participation and preparation.

APRIL 2011– SEPTEMBER 2011

PHARMACY BENEFITS MANAGER AND PRIOR AUTHORIZATION SPECIALIST, CPHT, Coventry Healthcare

Job Responsibilities:

• Pharmacy Benefits Management for Gallagher Bassett.

• Provide customer service for the pharmacy division of workers compensation at Coventry Healthcare.

• Process prior-authorization requests and update billing information for pharmacies.

• Work directly with insurance adjusters and pharmacists to approve medications for injured workers.

APRIL 2007– MAY 2008

SENIOR CERTIFIED PHARMACY TECHNICIAN (CPHT), Kindred Pharmaceutical Services/Pharmerica Corporation

Job Responsibilities:

• Fill prescription in both unit and bulk

• Prepare IV admixtures, and compound medications

• Stock medication

• Check and pull expired drugs

• Manage inventory

• Verify shipping container with log sheet

EDUCATION

MAY 2015

AAS IN HEALTH SCIENCE

Southern New Hampshire University

MARCH 2007

CERTIFICATE

Fortis College

MAY 2001

HIGH SCHOOL DIPLOMA

Sabino High School

SKILLS

Functional Testing

SugarCRM

Medical Insurance

Framework LTC

AS400

Insurance Verification

Managed Care

Pharmacy Claims Analysis

User Acceptance Testing

MedCo

QS/1 Data Systems

Pharmacy Auditing

Formulary and PDL Management

Pioneer Rx

Pharmacy Technician Experience

Quality Assurance

SDLC

CMW

Risxfacs

Admit24

Quality Engineering

EzQuery

Microsoft Office

Prior Authorization

Salesforce (SFDC)

Sequel

eProcare

Medical Billing

Drug Utilization Review and Management

RxClaims

Manual Test Cases

Agile

Internal Audits

Requirements Gathering

CERTIFICATIONS AND LICENSES

CPhT

February 2009 to June 2023

Nationally Certified Pharmacy Technician through the PTCB. License/Certification No: 470************

Registered Pharmacy Technician

January 2012 to June 2023

Registered Pharmacy Technician in the State of Georgia

GROUPS

ACFE

2015 to Present

Association of Certified Fraud Examiners

NADDI

2015 to Present

National Association of Drug Diversion Investigators

NSCS

2015 to Present

National Society of Collegiate Scholars

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