DANA MCRAE
Virginia Beach
Summary
Healthcare Operations and Pharmacy Support Professional with 12+ years of pharmacy claim review, provider outreach, prior authorization processing, PDE resolution, and utilization management experience. Entrepreneurial operator since 2010 with strong communication, accuracy, multitasking ability, training experience, and workflow optimization skills.
Overview
16
16
years of professional experience
Work History
Entrepreneur / Business Owner
01.2010 - Current
- Manage daily operations for Snaptime Photobooth, Staples x Statements, With LJ Children’s Books, and The Benefit of Believing.
- Respond to 50–100+ inquiries monthly with a 98% customer satisfaction rate.
- Process payments, resolve customer issues, and maintain accurate financial tracking across all brands.
- Coordinate and execute 40+ annual events with strong communication and time management.
- Maintain confidential customer, client, and financial data with full security and accuracy.
Pharmacy Technician SME
Anthem, Inc.
01.2015 - 01.2023
- Processed and reviewed 300+ prior authorizations per month across Medicare and Medicaid plans.
- Reviewed over 300 pharmacy claims monthly for accuracy, prior authorization requirements, clinical criteria, refill timing, quantity limits, coordination of benefits, and billing discrepancies.
- Completed 50–75 outreach calls weekly to pharmacies, providers, and members to resolve claim rejections, PA questions, gather clinical documentation and clarify claim discrepancies.
- Researched and resolved complex prescription claim issues including NDC mismatches, DUR edits, step therapy, duplicate therapy, plan limitations, and eligibility conflicts.
- Processed pharmacy claim reversals, remittance requests, and claim reprocessing for corrected claims, overrides, and adjustments.
- Checked claims for overpayments, eligibility issues, coordination of benefits, and regulatory alignment.
- Researched and resolved complex pharmacy claim discrepancies using Medicare/Medicaid billing rules and policies.
- Resolved prescriber-related CMS PDE rejections within mandatory turnaround times with 98% accuracy and compliance.
- Verified and updated prescriber credentials (NPI, DEA, taxonomy), ensuring claims processed without interruption.
- Identified claim trends, recurring rejection patterns, and system issues, contributing workflow and process improvement recommendations.
- Assisted in training and mentoring new and current employees on pharmacy systems, claim workflows, and PA processes.
- Maintained 99% accuracy on documentation, system notes, PA determinations, and audit-required records.
- Delivered excellent customer service by educating members on medication coverage, formulary alternatives, denial reasons, and next steps.
Utilization Management Representative II
Anthem, Inc.
01.2012 - 01.2015
- Reviewed 1,000+ Medicare and Medicaid claims monthly
- Conducted 105+ outbound outreach calls to Medicare members to complete Health Risk Assessments (HRAs) and document clinical information.
- Prepared 200+ written notifications, EOBs, and recovery documents per month to support accurate processing.
- Maintained accuracy while working with confidential PHI and regulated data.
- Provided excellent customer service through high-volume phone and email communication with providers and internal teams.
Education
Bachelor of Business Administration (BBA) - Marketing
American Continental University
01.2019
Skills
- Pharmacy Prior Authorizations
- Claim Review
- PDE Resolution
- Provider & Pharmacy Outreach
- Claims Reversals
- Remittance Requests
- CMS Requirements
- Medicare/Medicaid
- Inbox Triage
- Microsoft Outlook/Excel/Word
- Customer Service
- Process Improvement
- Staff Training & Mentorship
Timeline
Pharmacy Technician SME
Anthem, Inc.
01.2015 - 01.2023
Utilization Management Representative II
Anthem, Inc.
01.2012 - 01.2015
Entrepreneur / Business Owner
01.2010 - Current
Bachelor of Business Administration (BBA) - Marketing
American Continental University