Jeff Baker is currently a Senior Consultant with BluePeak Advisors and has been actively engaged in the Medicare Part D industry since 2007. Jeff has over 15 years of management experience and his expertise includes a comprehensive insight into the Medicare Part D claim adjudication environment, Medicare payment methodologies, and a solid aptitude to interpret new and existing Medicare guidance.
Jeff has a proven track record of leading operational and technical teams in achieving defined goals within the complex Medicare environment. Jeff has a solid background and understanding of statistical techniques and has developed sustainable solutions to track monthly CMS premiums, reconcile quarterly coverage gap discount payments, and perform Prescription Drug Event (PDE) financial reconciliation. Jeff has partnered with Medicare drug plans to perform in depth analysis into their PDE data to identify areas of non-compliance as well as developing a compliance roadmap to remediate any issues while optimizing CMS reimbursements.
Within BluePeak Advisors, Jeff has collaborated with various health plans and Pharmacy Benefit Managers (PBMs) to test and validate several complex Medicare Part D adjudication functions including formulary demonstration, plan benefit, CMS subsidies, pharma discounts, and transition of care logic. Using his experience of claims processing and formulary administration, Jeff has supported numerous program audits and has conducted several validation and mock audits with his primary expertise in Part D Formulary Administration (FA).
Prior to BluePeak Advisors, Jeff worked for a large PBM where he became a program manager over several Part D programs including PDE reporting, CMS required reporting, and the claim reprocessing program. Jeff then set out to start a new Employer Group Waiver Plan (EGWP) where he managed several key financial operations including the underwriting of employer group premiums, budget management, and reporting and forecasting plan costs and CMS reimbursements. Jeff also monitored plan compliance standards and collaborated with the PBM to develop solutions to remediate any identified adjudication, formulary, or PDE issues.
Jeff currently resides in San Diego, California and holds a Bachelor of Arts in Psychology from California State University, San Marcos.