Medical Clinical
Resume:
John Scott Valley
Costa Mesa, CA 92626
Phone: 714-***-****; E-Mail: ********@*****.***
Experience
UnitedHealthCare, Cypress, CA
Clinical Pharmacist Contractor, Appeals and Grievances Department November 13, 2017 - March 21, 2018
•Evaluate patient histories and interpret physicians' clinical documentation while assessing clinical criteria and compendia support.
•Consult with customers, patients and/or physicians regarding use of medications, potential drug interactions, and clinical status for appeals requests.
•Review formulary and utilization management guidelines to determine if the drug should be a covered benefit for the beneficiary based on their medical history. Primary clientele includes Medicare Part-D beneficiaries.
•Gather complex clinical information and evaluate approved compendia, medical literature, and coverage policy to render decisions. This often requires consultation with Plan Medical Directors and the beneficiaries treating physician.
OptumRx, A UnitedHealth Company, Costa Mesa, CA
Clinical Pharmacist, Compliance. March 2015 – September 2015
•Served as team member dedicated to monitoring reports and Prior Authorization cases for compliance risk.
•Served as point person in preparing and packaging appropriate documentation relative to out-of-compliance cases for delivery to CMS.
•Maintained database of past and current cases posing compliance risks.
•Aided and served as lead in fielding compliance queries from the Prior Authorization production team, which lead to increased adherence to clientele service level agreements.
OptumRx, A UnitedHealth Company, Costa Mesa, CA
Clinical Pharmacist, Clinical and Communication: Verbiage Template Development. November 2013 – March 2015
•Developed core verbiage templates for utilization in Prior Authorization decision processes, which lead to enhanced scales of efficiency in Prior Authorization inventory processing.
•Served as subject matter expert for Prior Authorization System (PAS) verbiage templates.
•Provided training on verbiage template validation.
•Collaborated with other teams to successfully build customize verbiage templates and communicate progress to leadership.
•Participated in quality checks to ensure verbiage template accuracy.
•Maintained drug-specific database of past and current verbiage templates.
OptumRx, A UnitedHealth Company, Costa Mesa, CA
Clinical Pharmacist, Prior Authorization. February 2001 – November 2013
•Reviewed Prior Authorization cases and rendered coverage determinations based on clinical criteria and patient benefit design; lines of business included Medicare Part D, Medicaid, and Commercial (PacifiCare); Case Rate: 95th percentile; Case Decision Quality: 99th percentile.
•Consulted with medical staff members and physicians in order to obtain necessary clinical information to appropriately render case decisions and to address interpretations of clinical guideline criteria and coverage determinations so rendered.
•Participated and contributed to Prior Authorization clinical medication guideline development and revision process.
•Participated in quality improvement and process enhancement projects as they were assigned.
•Reviewed and validated various benefit guidelines contained in the Prior Authorization System.
•Coordinated updates required for the Prior Authorization System between the team and BPM Ops.
•Developed and maintained drug-specific provider request fax forms.
•Monitored reports and Prior Authorization cases for compliance risk.
•Prepared and organized team’s on-call and department phone schedule.
•Prepared monthly team meeting minutes.
•Assisted pharmacist technicians in resolving issues related to Prior Authorization requests.
•Served as a subject matter expert for case review.
•Served as primary trainer of new hires to the Prior Authorization Department.
Education
University of Southern California, School of Pharmacy, Los Angeles, CA
Doctorate of Pharmacy Graduated May 1999
University of California, Los Angeles, Los Angeles, CA
Bachelor of Science in Psychobiology Graduated June 1995
Certifications
Registered Pharmacist: License # 51595
California Board of Pharmacy
American Pharmacists Association Pharmacy-Based Immunization Delivery Certification
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