I have over five years of experience managing pharmacy benefit programs, including formulary management, drug utilization review, and cost containment strategies. I have worked with various stakeholders, including pharmacies, insurers, and pharmaceutical manufacturers, to ensure optimal patient outcomes while controlling costs. My expertise includes analyzing claims data, negotiating contracts, and implementing clinical programs to improve medication adherence and reduce unnecessary expenditures.

I stay updated on federal and state regulations, such as HIPAA, ERISA, and CMS guidelines, to ensure compliance. I conduct regular audits, maintain detailed documentation, and collaborate with legal and compliance teams to address any gaps. Additionally, I implement training programs for staff to ensure they understand and adhere to regulatory standards, minimizing risks and ensuring the organization operates within legal frameworks.

In a previous role, I implemented a step-therapy program that required patients to try cost-effective medications before moving to higher-cost alternatives. By analyzing claims data and collaborating with prescribers, we reduced costs by 15% while maintaining patient satisfaction and health outcomes. This approach ensured patients received effective treatments while aligning with the organization’s financial goals.

I approach conflicts with a focus on collaboration and problem-solving. I listen to all parties, review the specific case details, and ensure decisions align with the benefit plan’s guidelines and patient needs. By maintaining open communication and providing clear explanations, I help resolve disputes amicably while upholding the integrity of the pharmacy benefit program.

I implement targeted interventions such as patient education, medication therapy management, and automated refill reminders. By analyzing data to identify non-adherence patterns, I design programs that address barriers like cost or side effects. Collaborating with healthcare providers and leveraging technology, I ensure members receive the support they need to adhere to their prescribed therapies, improving health outcomes and reducing costs.