ADDIE L. MERCADO
Guaynabo
Summary
Solutions-oriented expert who believes that unwavering dedication and consistency are key to cultivating impactful business relationships.
Overview
9
9
years of professional experience
Work History
TPA MANAGER
SUFFOLK ADMINISTRATIVE SERVICES LLC
Guaynabo
10.2024 - Current
- Review and evaluate Third Party Administrator (TPA) performance at regular intervals.
- Oversee TPA operational activities to ensure compliance with Federal regulations.
- Perform quality checks on the benefit setup and coding on Medical and Pharmacy Claims to confirm plans are aligned with Plan documents.
- Manage and oversee implementation and transition processes with new and existing TPAs.
- Perform quality assurance to check-run files before moving to funding phase.
- Collaborate with carrier team members who support claim and validation.
- Collaborate with the General Counselor to review and investigate any grievance or complaint received.
- Collaborate in the creation of compliance documents such as Summary of Benefits, Summary of Plan Documents, among others.
PHARMACY SPECIALIST
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
SAN JUAN
07.2022 - 10.2024
- Oversaw and monitored the Pharmacy Benefit Manager (PBM) activities, such as implementing benefit changes.
- Reviewed pharmacy and medical component claims.
- Oversaw Medicaid Rebate Program implementation and performed quality check and reconciliation to quarterly claims to be submitted to CMS.
- Create state policy regarding pharmacy programs, review and update the policies that required changes based on new CMS guidelines.
- Draft normative letter and disclose them to all pertinent parties.
- Collaborate will other Department of Health agencies such as ASSMCA and Ryan White.
COMPLIANCE OFFICER
PUERTO RICO HEALTH INSURANCE ADMINISTRATION (PRHIA/ASES)
San Juan
10.2021 - 07.2022
- Review, develop and implement agency's compliance policies and programs. (Medicaid)
- Create and manage corrective action plans in response to discoveries and compliance violations by the contracted Medical Care Organizations.
- Regularly monitor MCOs practices, and documents to identify potential weaknesses or risks.
- Performs FWA activities such as auditing, monitoring, data analysis, and review Providers & Members Survey.
- Create and collaborate with reporting assessments that may impact public governance.
- Create and develop internal regulatory projects and outline to share to the Executive Department as required.
- Provide resolutions on any project assigned by the Chief Compliance Officer.
CLIENT COORDINATOR
ABARCA HEALTH
San Juan
12.2020 - 08.2021
- Manage operational calls, scheduling internal and external meetings, agenda development, requests and actions items capture during the meetings.
- Be the first-tier support for the adjudication platform.
- Perform audits, monitor claims for Commercial and Medicare clients and report back to client or delegated third party.
- Prepare and request client's reports.
- Generate and analyze reports to make internal recommendations and to the client.
- Working and interacting with internal teams to anticipate client's needs.
- Perform testing on system enhancements for client requests.
ACCOUNT MANAGER
ENVISIONRX
San Juan
04.2017 - 06.2020
- Provided strategic management of activities related to pharmacy benefit implementation.
- Created testing scenarios, complying with internal and external timelines and client requests in a timely manner.
- Provide consultative support to operational departments such as Clinical, and the Benefit Team.
- Performed testing on system enhancements for custom client requests.
- Solved and provide an accurate resolution of issues.
- Contact various parties to resolve the point of service issues and advice regarding adjudication requirements.
- Contribute to government audits consisting of research, analyzing, and reporting any potential issue.
- Resolve day-to-day issues to internal departments and assigned client.
- Collect SLA metrics, and report to the client on the recurrency stablished in the Contract.
- Collaborate with the Compliance on audits requested by CMS such as PDEs, Formulary, Benefit and FIR.
ACCOUNT REPRESENTATIVE & ADMINISTRATIVE ASSISTANT
ENVISIONRX
San Juan
09.2016 - 04.2017
- Support groups implementation.
- Collaborate with the benefit plan setup and testing.
- Make certain testing timelines and special projects are met.
- Provide support to other operational departments by researching issues and perform user-acceptance testing on system enhancement.
- Documenting and communicating test results to the account managers and assigned clients.
- Perform marketing materials validation.
- Solve and provide timely and accurate resolution of system issues.
- Contact pharmacies to resolve point-of-sales issues.
- Perform administrative and clerical activities to support the office staff.
- Perform general office duties including monitoring invoices, faxing, office supply management and coordination of department meetings among.
- Provided administrative assistance including receiving visitors, coordinating events and projects, maintaining office budgets, booking meetings, preparing agendas, taking, and distributing minutes, securing travel arrangements, and preparing expenses claims.
Education
MBA - ACCOUNTING
INTERAMERICAN UNIVERSITY
SAN GERMAN, PR 08.2020 - 01/2023
Bachelor of Arts - OFFICE SYSTEM MANAGEMENT
INTERAMERICAN UNIVERSITY
SAN JUAN, PR 01.2016 - 01/2018
Skills
- Windows Office
- CPht
- Medical Billing Certification
- Monday
- CRM
Timeline
TPA MANAGER
SUFFOLK ADMINISTRATIVE SERVICES LLC
10.2024 - Current
PHARMACY SPECIALIST
PUERTO RICO HEALTH INSURANCE ADMINISTRATION
07.2022 - 10.2024
COMPLIANCE OFFICER
PUERTO RICO HEALTH INSURANCE ADMINISTRATION (PRHIA/ASES)
10.2021 - 07.2022
CLIENT COORDINATOR
ABARCA HEALTH
12.2020 - 08.2021
MBA - ACCOUNTING
INTERAMERICAN UNIVERSITY
08.2020 - 01/2023
ACCOUNT MANAGER
ENVISIONRX
04.2017 - 06.2020
ACCOUNT REPRESENTATIVE & ADMINISTRATIVE ASSISTANT
ENVISIONRX
09.2016 - 04.2017
Bachelor of Arts - OFFICE SYSTEM MANAGEMENT
INTERAMERICAN UNIVERSITY
01.2016 - 01/2018