Proprietary

Edward Saucedo

San Antonio TX * 210-***-****

adu5ti@r.postjobfree.com

SUMMARY

• I am the person who is data savvy, able to interpret data and analyze trends through root cause analysis for process improvement. A background in Medicare and Pharmacy where I have worked in the retail pharmacy setting along with call center (PBM) experience as a pharmacy technician.

• Proficient use of Microsoft office suite

• Highly skilled computer literacy, critical thinking skills

• Able to influence without direct authority

• Ability to effectively communicate with technical, business and management staff

• General Business/Turning Data into Information

• Applying Reasoned Judgment

• Leadership/Collaborating for Results

• Service/Working Across Boundaries

• Maximizing Work Practices

EDUCATION

Education Level Obtained: Graduate Certificate

Institution: Pharmacy Technican Certification Board San Antonio, TX

GPA: 3.5

Graduated: Yes

Graduation Date: 07/31/2000

Area of Study: Pharmacy Technician

Proprietary

Education Level Obtained: High School Graduate

Institution: Southwest High School

San Antonio, TX

Years Attended: 1994 - 1997

GPA: 3.5

Graduated: Yes

Graduation Date: 06/30/1997

Area of Study: BIOLOGY

EXPERIENCE

INTERNAL WORK EXPERIENCE

JOB: QUALITY CONSULTANT/ MCR RPH CLINICAL OPS with Aetna/CVS pharmacy Title: QUALITY CONSULTANT/ MCR RPH CLINICAL OPS

Start Date : 2/12/2013 - PRESENT

Key Accomplishments: Position Summary

Working as an Administrative and clinical reviewer in my role as a Quality Consultant under the supervison of Angela Puerzer and Gregory Stephen are assisted by SAS programming in selecting potentially inappropriately rejected claims. The SAS program takes all daily rejected claims and applies administrative and clinical coding logic. Most of the daily rejects are filtered by the automated program logic. The program then produces a file of claims rejected for administrative codes and another for clinical reject codes; and these are then reviewed by the Quality Management team to determine whether further investigation is needed. After the initial review by the Clinical Reviewer any potentially inappropriate rejections which require further review by the Business Owner(s) are taken to the Daily Issues Resolution Workgroup (IRW)1 for research and discussion. Below is a graph of what Clinical resources we use for our job function:

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Clinical Resource Resource Description

Rx Claim, PeopleSafe,

and DPAS

Adjudication application that houses:

• Member Information

• Rejection Transaction details

• Rx History

• Previous & Current PA/Overrides

Zynchros Online formulary tool

• Displays expected plan design

• Displays expected tier & edits

*Zynchros is updated monthly between the 26th of the month and 3rd of the next month.

Drug Updates Various sources used to provide information on newly FDA approved drugs and formulary additions.

• Medispan

• Change Management emails

• Targeted Reviews

• CVS Caresourse Criteria

JOB: QUALITY SUPPORT ANALYST with Aetna/CVS pharmacy Title: QUALITY SUPPORT ANALYST

Start Date : 9/10/2012 – 2/12/2013

Key Accomplishments: Position Summary

Provides the office support needed to ensure that business objectives are met. Performs functions related to providing information services to business area. Follows a pattern of operations generally standardized, but frequently includes rules, expectations and special instructions, which demand close attention to detail to support business reporting needs under the supervision of Anthony Allotta and Gregory Stephen.

Opportunities: To advance my career in the Medicare field for the senior leadership role, Project coordinator, as well as in the informatics department. Role in the position: Fully investigates issues to determine the root cause to prevent issues from recurring and remediates issues related to inappropriate rejected pharmacy claims. POLICY:

Aetna objectives are to search for, correct and remediate issues causing Medicare Part D claims to reject inappropriately; identify each issue’s root cause and the scope of beneficiary impact to determine appropriate issue remediation action items; develop, implement, and test resolution Proprietary

project plans detailing beneficiary and systems remediation; and communicate issues and resolutions regularly to Senior Leadership and Compliance via daily reports and/or calls. Compliance participates and has full visibility to all issues and research. Skills:

* Uses designated systems to obtain information to support reporting needs. Understands the impact of actions on system primarily used/maintained in day to day activities

* Responsible for unit administrative needs: distribute work, support applications

* Devises record keeping methods, including but not limited to spreadsheets to report and track backlogs, work distribution, and compliance inventory, etc

* Uses system output to monitor and reconcile monthly reports. Monitors, reviews, researches, reconciles and balances designated system activities

* Answers routine requests of simple to moderate complexity by monitoring business unit mailboxes. Trouble shoot system access issues, provide assistance with business unit applications and systems

* Prepares specialized reports, gathering, summarizing and analyzing data and developing recommendations for manager. Analyzes and verifies system results to ensure accuracy, accountability and data integrity

* Identifies and resolves problems and escalate to management as defined in unit guidelines

* Reviews and analyzes system reports and other information to develop financial information for use in reporting

Exhibits Quality Support Analyst Behaviors

- Understanding of healthcare industry, healthcare data, common healthcare terminology and medical cost issues & strategies.

- Skilled in complex clinical and financial data collection, modeling & analysis, able to work with Microsoft Excel, Microsoft Access and understand relational database concepts.

- Strong SAS Query skills (SAS BASE, SAS MACROS) or equivalent experience.

- Development in Access/Excel and prior pay for performance experience.

- Ability to meet tight deadlines within context of potentially changing priorities, working both independently and facilitating cross-functional solutions.

- Capable of taking project through issue identification, design specifications, data query/programs, financial analysis and resolution/recommendation stages. Proprietary

- General Business: Turning Data into Information, Communicating for Impact and Ensuring Project Discipline

- Service: Working Across Boundaries

- Benefits Management: Promoting Health Information Technology

- Technology: Leveraging Technology

- Trained using Aetna's Systems such as APMCAS, Zynchros, E2E Paid claims, SharePoint, CVS Systems such as AS400, People Safe, MedHok, CareSource.

JOB: PRECERTIFICATION PHARMACY BENEFIT MANAGEMENT with Aetna/CVS pharmacy Title: Inbound Queue Associate

Start Date : 11/01/2010 – 9/10/2012

Key Accomplishments: INBOUND QUE ASSOCIATE FOR AETNA/ CVS CAREMARK PRECERTIFICATION DEPARTMENT

Position Summary:

- Quality Assurance Specialist - (QRT) Quality Review Technician under Beverly Alvarado's supervision.

- Precert phones, (MOD) Mail Order Delivery Precert phones, MOD KC phones, MOD Pompano phones

- Fax Rejects

- (SHL) Special Handling Line ; Situational meds Specialist

- (MOD) Mail Order Delivery focus group member

- Employee Spirit Committee member under Kevin Sauceda's supervision. JOB: PRECERTIFICATION PHARMACY BENEFIT MANAGEMENT with Aetna/CVS pharmacy Title: Inbound Queue Associate

Start Date : 11/07/2005 - 08/13/2007

Key Accomplishments: Precert phones, MOD Precert phones, MOD KC phones, SHL situational meds only, MOD focus group member, Employee Spirit Committee member. Approval, denial and phone Quality has improved over the years while under Heather Donnon's supervision. Proprietary

EXTERNAL WORK EXPERIENCE

Title: Certified Pharmacy Technician

Organization: H-E-B Pharmacy

San Antonio, TX

Start Date : 11/01/2002 - 11/01/2005

Key Accomplishments: Able to transfer jobs with the same company back to San Antonio as a cpht. Title: Certified Pharmacy Technician

Organization: H-E-B Pharmacy

Austin, TX

Start Date : 09/01/2000 - 11/01/2002

Key Accomplishments: Being hired by a major chain pharmacy as a certified pharmacy technician while attending college at the University of Texas at Austin under the supervision of Larry Boenig and Eunice Erickson.

Title: Certified Pharmacy Technician

Organization: GARZA PHARMACY – Independent Pharmacy San Antonio, TX

Start Date : 07/01/1997 - 09/01/2000

Key Accomplishments: Transitioned from prescription delivery driver/ pharmacy clerk to a Certified Pharmacy Technician under the supervision of Owners Romeo Garza and Pedro Cuellar. Proprietary

SKILLS

• Customer Service

• Microsoft Office suites

• Retail Sales

• Data Entry

• Sales

• Power Point

• Cashier/Clerk

• Team Lead

• Reports/ Reporting

• Prescription Delivery Driver/Courier

• Certified Pharmacy Technician

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