Ivelisse Vargas Sepulveda
Caguas
Summary
Experienced Clinical Pharmacist with a PharmD degree and over 10 years in pharmacy benefits management (PBM) and health plans. Known for effectively leading clinical programs, optimizing CMS Stars ratings, and ensuring compliance with regulatory standards, including CMS, HIPAA, and URAC. Skilled in data-driven decision-making, cross-functional leadership, and strategic partnerships to improve patient outcomes, enhance medication adherence, and implement cost-saving measures. Expertise in Medication Therapy Management (MTM), Drug Utilization Review (DUR), and formulary management. Committed to advancing patient care, safety, and healthcare quality across large-scale programs, with a focus on staff training, process optimization, and fostering collaborative environments.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Pharmacy Quality & Clinical Programs Manager
MCS
San Juan, Puerto Rico
10.2021 - 03.2025
- Leads Quality & Clinical Programs, including Medication Therapy Management (MTM), Drug Management (DMP), Diabetes Integrated Programs, and Specialty Programs achieving measurable improvements in medication adherence
- Develops and implements CMS Stars rating strategies, achieving 5 stars rating through targeted interventions, including SPC, SUPD, Adherence RAS, DM, Diabetes, Polypharmacy, and COB
- Directs clinical initiatives aligned with NCQA, HEDIS, CAHPS, and HIPAA standards to uphold patient care, data privacy, and quality reporting
- Collaborates with providers, clinical partners, and vendors to foster quality improvement and ensure CMS compliance
- Manages vendor contracts and monitors performance, implementing cost-saving measures that generate a ROI from MTM, Diabetes programs and Specialty programs
- Designs health education materials for MCS members and stakeholders to enhance engagement and program effectiveness
- Contributes to annual departmental budget development, monitors discrepancies, conducts root-cause analysis, and recommends actions to ensure financial alignment
- Provides guidance on pharmacotherapy to support therapeutic consistency across teams
- Mentors and trains team members, promoting performance excellence and a collaborative work environment
Clinical Pharmacist
Abarca Health
San Juan, Puerto Rico (Remote)
12.2016 - 09.2021
- Evaluated coverage determination requests, ensuring clinical appropriateness and compliance with CMS guidelines
- Executed Drug Utilization Review (DUR) programs using prescription data, medical claims, and formulary information to enhance clinical outcomes
- Made recommendations regarding care gaps, high-risk medications, drug interactions, therapeutic substitutions, compliance, and adherence
- Partnered with Health Educators and Case Managers to ensure MTM participants received necessary program information
- Analyzed and streamlined clinical workflows, improving patient care, outcomes, and program quality
- Worked with cross-functional teams to execute clinical projects, operationalize formularies, and deliver high-quality client service
- Supported CMS Medicare STAR initiatives, Medicaid's Health Care Improvement Program, and other clinical programs, ensuring alignment with quality measures
- Participated in audits and served on the Pharmacy & Therapeutics Committee, preparing presentations and clinical recommendations
- Developed and documented Clinical Policies and Procedures for consistency and compliance
- Provided clinical support and drug information to PA Customer Service Teams, enabling informed decisions for beneficiaries
- Ensured CMS and URAC compliance across clinical processes, maintaining regulatory standards
- Analyzed medication trends and made recommendations for policy updates to improve patient outcomes
- Managed and mentored new staff, delivering focused training to enhance team competency and performance
- Advised physicians on accurate medication dosing, contributing to patient safety and effective treatment outcomes
- Provided consultations and addressed inquiries from patients, healthcare professionals, and physicians regarding drug use, potential side effects, and specified indications
- Adhered to all pharmacy laws and ethical standards, ensuring professional integrity
Staff Pharmacist
CVS
Caguas, Puerto Rico
10.2015 - 11.2016
- Interpreted and dispensed prescriptions accurately, ensuring patient safety and satisfaction with thorough checks for dosage, drug interactions, allergies, and contraindications
- Administered vaccines, supporting public health by providing immunity against influenza, pneumonia, and other diseases
- Recommended OTC devices and medications to support symptom management and patient care
- Partnered with management to implement in-store programs, boosting sales and customer engagement
- Supervised controlled substance dispensation with strict oversight and audit procedures for compliance
- Directed 4 Pharmacy Technicians, interns, and support staff, ensuring operational efficiency and regulatory adherence
- Compounded medications, including emulsions, liquids, powders, and ointments, with precise preparation techniques
- Maintained state and federal records of controlled substances, ensuring compliance with regulatory standards
- Resolved insurance rejections and billing issues efficiently, ensuring patients received timely access to medications
Education
Doctor of Pharmacy - PharmD
Nova Southeastern University
05.2015
Bachelor's - Chemistry
Universidad De Puerto Rico
Skills
- Clinical Quality Improvement
- Medication Adherence Optimization
- Healthcare Data Analysis
- Risk Management and Compliance (HIPAA)
- Population Health Management
- Pharmacoeconomics
- Health Literacy and Patient Education
- Claims and Utilization Management
- Patient Risk Stratification
- Stakeholder Collaboration and Cross-functional Leadership
- EHR Systems (Epic, Cerner)
- Microsoft Office (Word, Excel, PowerPoint)
- Data Analysis Tools (Advanced Excel, SQL, Tableau, Power BI)
- Puerto Rico Pharmacy License
- Operational Oversight
- Organized and Detail-Oriented
Certification
Member, American Pharmacists Association (APhA)
Languages
English
Bilingual or Proficient (C2)
Spanish
Bilingual or Proficient (C2)
Timeline
Pharmacy Quality & Clinical Programs Manager
MCS
10.2021 - 03.2025
Clinical Pharmacist
Abarca Health
12.2016 - 09.2021
Staff Pharmacist
CVS
10.2015 - 11.2016
Bachelor's - Chemistry
Universidad De Puerto Rico
Doctor of Pharmacy - PharmD
Nova Southeastern University