US Registered Nurse (NY) and Registered Pharmacist with a Doctor of Pharmacy degree and over 5 years of experience in Utilization Management, Clinical Appeals, and Pharmacy Benefit Management within U.S. healthcare systems. Skilled in medical necessity determination, prior authorization review, formulary and step therapy management, and Medicare appeals. Experienced in reviewing high-volume complex cases using MCG guidelines and payer policies while maintaining compliance with CMS standards. Strong background in pharmacovigilance, drug utilization review, and interdisciplinary clinical decision support across payer and PBM environments.
