I have extensive experience working with various pharmacy benefit management (PBM) systems, including but not limited to, adjudicating claims, managing formularies, and ensuring compliance with regulatory requirements. My role involved optimizing these systems to improve efficiency and reduce costs for both the pharmacy and the beneficiaries. I've also been responsible for troubleshooting system issues and training staff on new software updates to ensure seamless operations.

Ensuring compliance involves staying updated with the latest federal and state regulations, such as HIPAA and the Affordable Care Act. I regularly review and update policies and procedures to align with these laws. Additionally, I conduct training sessions for staff to ensure they understand compliance requirements. Audits are also a critical part of my strategy to identify and rectify any compliance gaps promptly.

In my previous role, I successfully negotiated contracts with pharmaceutical manufacturers to secure lower drug prices for our formulary. This required thorough market research, understanding the manufacturers' pricing strategies, and leveraging our volume to negotiate better terms. The outcome was a significant reduction in costs without compromising the quality of medications available to our members.

I approach disputes with empathy and a focus on resolution. First, I listen to the member's concern to fully understand the issue. Then, I review their benefits and the specific situation to identify any errors or misunderstandings. I work collaboratively with the member and relevant departments to resolve the issue promptly, ensuring the member feels heard and satisfied with the outcome.

Cost control strategies include formulary management, where we prioritize cost-effective medications without sacrificing quality. I also implement utilization management programs to ensure medications are used appropriately. Negotiating rebates and discounts with manufacturers and pharmacies is another key strategy. Regularly reviewing and adjusting these strategies based on performance data helps maintain a balance between cost and quality.