Prior Authorization Pharmacist

Sri Thao

***********@*******.*** 651-***-****

Professional Experience:

Blue Cross Blue Shield of MN, Aug 2015 – current

Senior Processor/Pharmacy Combined Operations

Responsibilities:

Trace Investigator. Contact patients who have tested positive for disease and trace steps prior to onset date of infection. Provide quarantine guidelines to patients and families as recommend by the CDC. Investigate if patient has had any contact with family, co-workers or have been in a critical infrastructure.

Work with PBM to resolve issues as well as locate trending problems that may occur due to system errors or credits not being adjusted or applying correctly.

Monitor and research claims at the PBM that have processed causing an overage and/or any discrepancies regarding medical and RX claims.

Compare and analyze data to make sure that claims processed accurately and patient information matches from the PBM to Highmark.

Resolve discrepancies by adjusting claims and following correct protocols to ensure correct payments are made to the member.

Ensure claims are paid or rejected correctly.

Used MS Excel for trending analysis and data quality certification by comparing records counts, and tracking data metrics such as null values and other known or expected parameters and thresholds to ensure data met quality standards.

Participate in CMS-Medicare Part D related RAC audits. Utilize Rx claim adjudication system to investigate claim processing for individual pharmacies

Responsible for testing, quality assurance, implementation of automation for processing claims. Identify insurance coverage and collaborate with other departments as needed to resolve patient inquires. Effectively communicate with the PMB’s to resolve issues.

PBM knowledge for Prime Therapeutics, CVS, Navitus, and ESI. Work daily in their system to match both RX and medical claims and assure there is no overage beyond members deductible and copays.

Hill-Rom Advanced Respiratory Government, St Paul, MN Dec 2010 – May 2014

Billing Specialist

Responsibilities:

Bill, review and correct Medicaid claims (CPT codes/modifiers, dates, authorization etc.) and submit via electronic, paper or handwritten as well as manually type claims and resubmit to payers.

Locate Medicare payments/denials online and resubmit primary claims with secondary payments or private insurance EOB if necessary.

Review denials and obtain correct information for reprocessing and research eligibility via phone/internet and enter correct demographic information in computer system.

Train employees on payer websites regarding submitting claims, checking status, patient eligibility and teach them how to read information from the website.

Work on credit reports and reconcile on accounts as needed. Process adjustments on claims when necessary, file appeals on behalf of patients.

Call patients and go over patient statements and set up payment plans. Duties also included posting payments from payers.

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