SHIRLEY RIVERA
Bayamon,Puerto Rico
Summary
Detail-oriented Licensed Pharmacy Technician with 4+ years in healthcare and specialty pharmacy. Specialized in managing insurance processes, documentation, and case tracking while ensuring data accuracy. Collaborated effectively with medical offices, providers, and insurance plans to streamline workflows and resolve documentation issues, enhancing service delivery.
Overview
1
1
Language
1
1
Certification
14
14
years of professional experience
Work History
Prior Authorization Specialist
OPTUM RX
07.2023 - Current
- Processed high-volume prior authorization calls and requests, ensuring accuracy of patient, medication, insurance, and authorization information in designated systems.
- Review submitted documentation for completeness and identify missing information required to process cases; communicate requirements to physician offices and healthcare providers.
- Maintained organized case records while adhering to established procedures, productivity standards, quality requirements, and time-sensitive deadlines.
- Documented, updated, and tracked case information using Panda, PAS, and Advocate Central to support efficient processing.
- Audit customer satisfaction/NPS calls, document findings, and identify quality opportunities for supervisor review.
Case Manager - Specialty Medications
MEDPLUS SPECIALTY PHARMACY
01.2022 - 07.2023
- Managed specialty medication cases from prescription intake through final delivery, maintaining accurate records throughout the workflow.
- Processed prescriptions and submitted cases to insurance plans for coverage determination, ensuring timely authorization and fulfillment.
- Reviewed case requirements and coordinated with medical offices, insurance plans, patients, and pharmacy teams to resolve access issues and prevent medication delays.
- Tracked cases and coordinated medication delivery to meet time-sensitive operational deadlines.
Case Manager - Oncology Specialty Medications
ONCO360 - MEDPLUS SPECIALTY PHARMACY
01.2022 - 01.2023
- Opened records for new patients, entering and maintaining prescription and patient information in pharmacy system to ensure accurate medication management.
- Submitted prescriptions to insurance plans, coordinating prior authorization and coordination of benefits (COB) to streamline patient access to medications.
- Assisted with copay/foundation assistance for high-cost medications and coordinated cases through completion.
- Assisted with copay/foundation assistance for high-cost medications, coordinating cases to completion to support patient access and adherence.
Customer Service / Café Associate
ESQUINITA COFFEE
01.2018 - 01.2020
- Handled multiple tasks in fast-paced environment, delivering professional customer service and facilitating team operations.
- Prepared and served high-quality coffee beverages to customers.
- Maintained cleanliness and organization of the cafe environment.
- Assisted customers with menu selections and special dietary needs.
Customer Service Associate
WALMART
01.2013 - 01.2018
- Assisted customers in high-volume environment, ensuring accuracy and adherence to service standards.
- Assisted customers with product inquiries and store navigation.
- Resolved customer complaints through effective communication and problem-solving.
- Processed transactions accurately using point-of-sale systems.
Education
Associate Degree - Pharmacy Technician
Ana G. Méndez University
Skills
- Pharmacy case management
- Pharmacy Operations & Documentation
- Insurance & Coverage Processes
- Documentation Review & Data Accuracy
- Prescription & Pharmacy Records
- Benefits coordination
- Provider / Physician Office Communication
- Healthcare Systems / Portals
- Data Entry & Record Maintenance
- Performance Auditing
- Deadline Management
- Patient Assistance Programs
- Bilingual Communication
Certification
- Licensed Pharmacy Technician, Puerto Rico, Active License
- PTCB Certification Examination, In Progress
Languages
- English
- Spanish
Systems
- English
- Spanish
Languages
English
Beginner
A1
Timeline
Prior Authorization Specialist
OPTUM RX
07.2023 - Current
Case Manager - Specialty Medications
MEDPLUS SPECIALTY PHARMACY
01.2022 - 07.2023
Case Manager - Oncology Specialty Medications
ONCO360 - MEDPLUS SPECIALTY PHARMACY
01.2022 - 01.2023
Customer Service / Café Associate
ESQUINITA COFFEE
01.2018 - 01.2020
Customer Service Associate
WALMART
01.2013 - 01.2018
Associate Degree - Pharmacy Technician
Ana G. Méndez University