Experience
Developed suite of clinical offerings for private payer and managed markets.
- Brought full-scale offering of clinical programs, target edits, DUR services and network structures to the client population both on a managed care platforms and commercial markets.
- Designed the a la carte offering that is currently utilized for private payer markets and managed care suites for 3+ million in various national markets.
Clinical account model formulation and team build.
- Fully constructed clinical account engagement and interaction model with team covering 3+ million members in both managed care, private payer and municipal membership populations.
- Conceptualized and implemented clinical reporting tools as well as client interface model for all populations, including drug forecasting, utilization models and trend projections.
- Designed seasonal variability algorithm in utilization protocols and membership modeling.
Pharma rebate procurement offering for multiple business lines.
- Led the clinical organization in its development of a full rebate services RFP.
- Layered traditional and specialty rebates based on population demographics for each market.
- Negotiated support model most appropriate for each business line.
- Recommended overall solution and engagement model based on organizational targets and global initiatives.
Supported data analytics initiative to fully integrate pharmacy, medical and laboratory data with actionable results.
- Work included assessing current state to identify capabilities and gaps, as well as optimal desired outcome.
- Developed target list of actionable outcomes from overall program scope and obtained health plan agreement.
- Identified key resources needed both internally and externally for project success, and provided budgetary analysis for resource allotment.
Provided assumed/full risk formulary formulation for highly specialized populations.
- Worked with Federal regulators and State/County officials to create and operationalize both segmented and full care solution formularies for targeted populations.
- Intermediated pharmacy network and payer interactions and agreements for formulary acceptance and seamless member experience.
Developed provider relations interface enhancements for clinical determination teams.
- Analyzed existing interface model and identified areas of risk.
- Worked closely with network providers and internal clinical team to create process and system improvements. Several aspects were directly related to NCQA corrective action plan initiatives and on subsequent audit received significantly improved scores.
- Network provider satisfaction scores were increased across all plans and networks.
Enhanced clinical review appeal services and processes in order to increase regulatory assessment scores.
- Provided regulatory review and interpretation of existing appeal processes.
- Identified key areas of risk and developed policies and procedures for enhancement.
- Worked with internal directors and managers to train and operationalize revised processes.
- Monitored and reported changes in assessment scores periodically to ensure success.