wchekesha@gmail.com 19 Hamil Ct Clifton, NJ 07013 (201) 467-7395https://www.linkedin.com/in/chekesha-west-10193193

HIGHLIGHTS Fifteen plus years of experience within the Pharmaceutical Benefit Management and

Medical Healthcare Industries. Pharmacy Benefits Build Team Experience Level 1. Independent management of all benefit design requests and performance guarantees. Managerial Experience: Billing Manager at a DME/Respiratory Therapy Co Performed Medical Policy/Case Management Review under the NJ State Health

Benefits Program. Complex Issue Resolution on both Managerial and Service levels: both Client and

Member facing. Claims Processing: Institutional and Professional- Resolution and Adjudication. Audit Support: Medical and Pharmaceutical.

EDUCATIONSaint Peters University, NJ

1992-1993 Course Work Completed Business Management, Marketing, and Business Math

Honors : Deans List, GPA : 3.5

EXPERIENCEAxelon Services Corp@ Horizon Blue Cross Blue Shield NJ

44 Wall St FL 18, New York, NY 10005Pharmacy Benefits Specialist (Level 1 Build) November 2014 – August 2015

Performed liaison duties between HBCBS account management and Prime Therapeutics resolving various benefit set-up and service issues as it related to agreements, coding and interpretation.

Spearheaded conversations to raise awareness and unearth interdepartmental and systemic limitations that caused short falls in our overall processes.

Shared the information with my manager and team to explore ideas for improved PBM communication & accuracy.

Obtained team buy in to create a document that identified numeric values used for unique benefit build requests eliminating build duplication; thereby decreasing delays, erroneous plan cancellations, and inappropriately attached live benefits.

Ensured operational compliance with PBM vendor to support MBU pharmacy sales and

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marketing effort. Researched national benefit designs & measured accuracy of benefit setup. Upon

completion of research, made determination if corrections were necessary and proceeded with modifying existing benefit designs.

Assisted the pharmacy build team by performing peer review audits, gathering error trends and providing feedback for corrections in an effort to decrease rate of error by at least 50%.

Supported internal Pharmacy Sarbanes-Oxley Liaison. Created and maintained all necessary documentation, identify gaps for remediation accordingly.

Express Scripts Inc. (Formerly Medco) 225 Summit Avenue Montvale, NJ 07645

Pharmacy Account Team Coordinator /Client Services March 2006 – September 2013

Investigated, evaluated and settled claims, applying technical knowledge and human relations skills to effect fair and prompt resolution of cases and to contribute to proper payment.

Resolved complex issues and solved underlying miscommunications to eliminate negative claim exposure while prioritizing large volumes of Account Team priority requests from United Healthcare.

Examined claims investigated by insurance adjusters, to make further decisions for authorization.

Contacted or interviewed claimants, doctors, medical specialists, or employers to get additional information.

Prepared detailed chronological review and presented cases for discussion during account management meetings.

Installed member files to connect to Open Enrollment builds. Reviewed and managed the O.E. Process from the insurers and/PBM side by engaging functional areas and providing testing; decreasing opportunity for error. .

Proactively participated in conducting pre & post-installation account set-up audits identifying opportunities and possible oversights within client installations to assist in maintaining the accuracy of detail while clarifying points of intent as it relates to set up. Also fulfilled mini audit requests as requested by the client.

Reported overpayment, underpayments, and other irregularities while balancing the integrity of the client relationship and retaining the trust necessary for future up sale.

Supervised claims adjusters to ensure that adjudications were compliant to client contract agreements using creative thinking and custom solutions.

Managed the client relationship engaging and coordinating subject matter experts and interdepartmental resources to resolve complications while adhering to contractual turn-around times.

Documented all client-related cases using the appropriate software/tools. Met regularly with the Engagement Band Management Team to discuss the direction

and scope of work associated with the future goals, deadlines and events of our clients.

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Served various managers internally and externally on a daily basis with a book of business that spanned many different clients with very different needs.

Leveraged my abilities to adapt quickly and value individual needs to optimize the relationships and properly respond to each management style; seamlessly delivering quality solutions with outstanding results.

Attended periodic meetings with upper management and Executives to acknowledge individual and departmental achievements, goals and quarterly statistics.

Oversaw risk management efforts for mishandled drug delivery and determination of root cause and prevention.

Communicated unique client requirements to member facing areas to assure proper handling of complex set ups.

Assisted in making sure custom IBAAG/and member communications were updated and maintained as needed.

Met or exceeded performance level objectives consistently using my proven ability to analyze and problem solve.

Assisted United/ NAE, SME and Managers in conducting frequent reviews of plan information for various clients opening and managing Reliability tickets for problematic issues while speaking to the information gathered and organizing, managing and working with teams to obtain resolution thus mitigating financial and/or member disruption.

Performed exit audits for the transition team during the Express-Script/Medco acquisition.

Quality Homecare Providers Inc. 345 Grand Avenue Leonia, NJ Billing Manager/Billing Representative October 2002 – December 2003

Proactively found and fixed functional issues and assisted in systemic transition, identifying and entering billable equipment previously overlooked. As a result, revenue drastically increased, optimizing the rental potential of the overall business.

Increased revenue and overall improved sales resulted in a promotion to manager in just a few short months.

Managed overall department performance while following policies and procedures. Oversaw Billing and Account Receivable to Commercial Insurance Co., Medicaid,

Medicare and Members directly; ensuring compliance with all established policies and procedures and seeing it through to ensure member pay portions were collected and reconciliation was completed.

Provided continued support for system upgrades/implementations. Met production goals by providing staff assignments in correspondence with objectives

set. Maintained excellent communication interdepartmentally and served as a liaison for

other departments to improve the member experience from order placement, through delivery and the on-going maintenance of equipment.

Lead the department in record sales while engaging upper management with ideas for new direction.

Served as a valuable resource during external audits. Managed the Appeals Process for Commercial, Medicaid and Medicare claims for both

the Satellite office and Leonia, NJ Updated documents relating to office policy and procedure as determined and agreed

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upon with the owner Dr. Kazmir, the Operational Manager, the intake Manager, the Finance Department and myself and regulatory requirements.

Calmed irate customers who required a managerial contact for phone operations, and correspondence.

Set up and/or facilitated interdepartmental training/education. Liaison and overseer for the Satellite Billing Office handling Medicare and Medicaid

extended investigation into complex issues for billing compliance and resolution. Created job ads and position descriptions as well as assisted with the interview

process for prospective billing representatives. Created and implemented the use of various forms, letter and policies to improved

functional quality, reduce accounts receivable and handle legal issues for both the Intake Department and the Billing Department.

Responsible for overall data entry & maintenance of the purchasing system including product descriptions, purchase coding, pricing for in-house products & Medicare/Medicaid retail information.

Performed internal studies, project management, and tracked, reported & projected earnings.

Kelly Services @Cigna Healthcare. 9 Polito Ave. Lyndhurst, NJ 07071Provider Services Representative December 2001- September 2002

Authorized Provider requests for procedures and services, entering them systemically for use.

Obtained details for Provider Network initiation and reinstatement. Reached out to The Medical Director and Medical Advisory Review Board to obtain

status of requested approvals. Handled issues relative to physician transactions, interactions, inquiries, complaints

and comments. Took action to ensure appropriate changes to resolve provider issues and concerns. Prioritized data entry resolving provider needs while in taking & resolving upwards of

90 calls per day. Maintained effective relationships with the medical review board, nurses, & all other

departments attributing to the quick turn- around of escalations. Maintained a positive articulate and professional phone demeanor.

Horizon Blue Cross and Blue Shield NJ 33 Washington Str. Newark, NJ 07102

Medical Policy Specialist/Customer Service Representative October 1995 - July 2001

Reviewed member issues telephonically & in person for claims processing & appeals resolutions.

Received and documented incoming phone calls from members. Prioritized work for call volume incurred addressing the most urgent needs

first. Arranged billing, handled collection of payments and submitted for

processing.

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Notified members of claim investigation results and resulting adjustments. Maintained effective relationships with members, sales personnel and

internal departments, generating multiple happy letters and awards for going beyond.

Expedited professional and institutional claim processing using skills obtained in training for ICD9, Revenue, HCPC, CPT-4 coding and J coding.

Initiated institutional and professional case investigations, analysis and adjudication through quality assurance audits.

Trained in basic medical terminology and other anatomy based courses when promoted to a Medical Policy Representative for first and second level Case Review.

Rendered prompt & accurate medical policy determinations, with case completions for both members and providing physicians.

Excellent interpersonal & communication skills both written & oral. Performed special case needs analysis for patients and physicians &

utilized case review software to communicate decisions systemically and through letters on a daily basis.

Served as a liaison to communicate medical information and decisions rendered by the Medical Advisory Review Board for third tier considerations; interacting with various teams and entities simultaneously.

Underwent monthly quality assurance audits and exceeded production and quality guarantees on a consistent basis.

SKILLS. Quality Review Audits Leadership Presentation Meeting Facilitation

Independent Needs Analysis Benefit Review & Testing Renewal Change Management Implementation Support Complex Issue Resolution Critical Thinking Problem Solving Interpersonal & Communication skills: Written & Oral. Negotiation Phone skills (both

Client & Member facing) Customer Service Irate Member diffusing skills Cross-functional Team Player Case Management Review Claims Processing prior to ICD10 Evaluations/Employee Review Project Management Self- Motivated Determined to Succeed Research Accounts Receivable Project Management Various LMS courses

including Presentation Better Business Relationships HIPPA ERISA Diversity

SOFTWARE/SYSTEMS EXPERIENCE Siebel Universal Customer Service Workstation E-service Delivery System for tracking and analyzing pharmacy purchase data and authorization data Rumba for benefits processing CPL BET-used for Plan File Builds Lotus notes: HGI GEI NAEGS PHBIT All source of truth benefit design request tools (AS400) Live

claims system Ad Hoc Reporting Tools Reliability for ticket creation and management Case Management Review Systems for Appeals and Communications

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LMS Microsoft: Word Excel Power Point Outlook Adobe

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