Josephine N.

Experience

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  Walmart

  Oct 2010 - Jun 2021

  Pharmacy Manager

  Walmart - Cartersville, GA May 2019 to May 2021PharmacistMaintain and prepare med plan for patient when performing MTMEncourage and educate patients on medication adherencePharmacy manager Walmart - Trion, GA Mar 2019 to May 2019Administer immunizations and vaccines to patientsOffer OTC consultationManage and train staff according to company policy and procedureWalmart - Chattanooga, TN Jan 2012 to Mar 2019Pharmacy ManagerApplied leadership skills and best management practices in supervising the retail pharmacy staff while conducting inventory control.Walmart - Chattanooga, TN Oct 2010 to Jan 2012Staff PharmacistExemplify commitment in sharing knowledge and facilitating training to staff to further hone their knowledge and skills in pharmaceutical Show less

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  Optumrx

  Jan 2021 - Jan 2022

  Clinical Pharmacist

  Efficiently assess prescribed medication therapy for unnecessary medications, need for additional medications, ineffective medications, inappropriate doses, adverse drug reactions, and adherence concernsReview prior authorization requests and make determinations for drug products according to member benefits, established treatment protocols and clinical criteriaMake coverage determinations within the defined turnaround times and meet regulatory requirementsConduct Utilization Management Responsible for clinical criteria including analysis, monitoring of the industry trends and assist in development of the criteriaEvaluate and document clinical responses to therapy including prior adverse reactions and efficacyCollaborate with prescribers, interdisciplinary care teams, patients and/or caregivers to identify and develop patient-specific disease state therapy goalsDetermine appropriate interventions to resolve medication therapy problems, achieve goals of therapy and prevent new medication therapy problemsCommunicate professionally and discuss/document clinical recommendations to prescribers and interdisciplinary care teamsComplete CMR (comprehensive medication review) for eligible Medicare Advantage members. This involves contacting patients telephonically to review current list of medications on record, ensure record is up to date, discuss problems/issues with medications, and make recommendations based on clinical Show less

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  Blue Cross Blue Shield

  Apr 2022 - Oct 2023

  Clinical Pharmacist

  Blue Cross Blue Shield Apr 2022 to October 2023Prior Authorization PharmacistResearch, evaluate and make determinations on member and provider appeals of pharmacy coverage decisionsGather complex clinical information, coverage policy and criteria information and work within regulatory guidelines to make coverage recommendationsProcess pharmacy appeals, interpreting member and provider submitted clinical information, and researching clinical issues and assessing appropriatenessOrganizes workload, sets priorities, completes assignments in a timely manner and utilizes resources appropriately while complying with department program standardsPerforms all duties and functions in compliance with state and federal pharmacy laws and regulationsConforms with and supports department quality assurance and improvement guidelinesReview prior authorization requests and make determinations for drug products according to member benefits, established treatment protocols and clinical criteriaMake coverage determinations within the defined turnaround times and meet regulatory requirementsResponsible for clinical criteria including analysis, monitoring of the industry trends and assist in development of the criteria for the Pharmacy and Therapeutics CommitteeDevelop and design clinical edits to adjudicate claims and enhance drug utilizationProvide clinical guidance and support to the assigned pharmacy techniciansConduct Utilization management Lead a team by applying clinical knowledge, and skills, to complete a project according to specific requirements. Show less

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  Aetna, a CVS Health Company

  Nov 2023 - now

  Clinical Pharmacist Commercial Prior Authorizations

  •Evaluate prescriptions and patient histories• Interpret physicians' prescriptions and clinical documentation, accesses 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• Conduct Quality Assurance and verify the accuracy of all prescriptions to render appeal decision• Provide explanations and interpretations within area of expertise• Review formulary and utilization management guidelines to determine if the drug should be a covered benefit for the beneficiary based on their medical history• Research, evaluate, and make determinations on member and provider appeals of pharmacy coverage decisions• Gather complex clinical information, consider approved compendia, medical literature, coverage policy, and criteria information and work within regulatory guidelines to render decisions. Decision may require consulting with Plan Medical Directors and the beneficiaries treating physician.•Collaborates with multiple groups within CD&A, including answering clinical questions, collecting appropriate clinical/ medical data needed to perform clinical assessments, and reviews as per the health plan/employer agreed criteria within the designated service level agreements. •Reviews cases in progress and provides a Clinical decision regarding Prior Authorizations Tier Exceptions and Non-Formulary requests Show less