| | | 20,000+ Fresh Resumes Monthly | |
|
|
| |
Click here or scroll down to respond to this candidateCandidate's Name
Street Address 215th PlaceSauk Village Ill Street Address
PHONE NUMBER AVAILABLEEMAIL AVAILABLEPROFESSIONAL SUMMARYThirty-three years of combined experience in Healthcare Management, Data Entry, EDI in Nursing home facilities, Medicare State/Medical Billing; Medical Records/H.I.M, Mental Health, Group homes and Customer Service. Effectively communicate with internal and external mid to higher management to meet employer and client/customer expectations. Self-Motivated and eager to learn.KEY STRENGTHS:Innovative and solutions-focused Management Professional and Health Information Specialist with an impressive career demonstrating visionary leadership and progressive experience in a variety of capacities and environments within the federal government. Confirmed ability to combine time/resource-management skills and implementation of strategic health Information, administrative and operational initiatives that enhanced organizational viability, efficiency and competence.Forward-thinking leader and enterprising problem-solver with the capacity to develop constructive relationships with a diverse group of cross-functional agencies and business partners. Influenced key internal/external stakeholders, establishing a cooperative climate across multiple departments/divisions.A catalyst for positive change possessing superior interpersonal, analytical and conflict resolution skills along with a flair for building strong performance teams through talent assessment and employee engagement. Exceptional written and oral aptitude with broad business and technical acumen.WORK EXPERIENCECareCentrix Tampa, Florida (January 2018 - April 13 2021)Utilizations Management Clinical Review CoordinatorTracked cases that are recommended for denial thru all clinical databaseMaintained the data of high quality standards. Ran reports and Analyze data from the database.Monitored the Clinical Review queue in the CareCentrix workflow management system to assure cases were being processed in accordance with required turnaround times.Completed Administrative and Medical Necessity denial process.Completed Lack of Information template; follow up on requested information per process based on HP contractual agreement.Reviewed ebin records for possible missing information based on request and guidelines of dated informationWorked with operations departments, clinical, quality and correspondence departments to assure accuracy and timeliness processing from end to end.Provided issues resolution and escalation to management when appropriate.Leverages review decision tools where appropriate to automate utilization management review.Participated in special projects and performed other duties as assigned.Completed data authorization edits as needed /report any employee errors.Completed oral notification of approval/denials for Medicare NJ/BCBS/HORIZONCareCentrix Tampa, Florida (March 2016-Janurary 2018)Report Project Team LeadOverseer of staffing project team for the states of Georgia and Tennessee for referrals for home health and durable medical equipment and authorization for contracted providers of Cigna; Florida Blue and Aetna M/C payers.Overseer for the data entry of the missed start of care referral team, review reports; assign out work caseloads and to ensure all required fields and information has been completed appropriately based on processReviewed Report daily 4Xs a day to audit report of cases for missing or needed steps needed and sent to rep working case to assist with getting the cases staffed timely; use communicator to answer questions and assigned work to ensure each rep have max amount of cases to workMonitored and Audited sensitive facilities reports and request referrals; audit for missed opportunities to improve communication with referral sources, patients, doctors and with staffing effortsMonitored any missed start of care cases and contributing factors to improve efficiency with re-education of trending patterns of missed opportunitiesProcessed data entry of identified missed starts of care cases for internal reporting on opportunities missed and contributing factors for re-educational training and email communication for trending errors.Ran and reviewed reports for staffing and authorized servicesParticipated in special projects and perform other duties assigned.Took on lead roles and training to co-workers when requested.Practice of PHIMonitored Ques and Bins for staffing assignment and work productivityActed in supervisor capacity as neededCollaborated with president and vice president of operations; medical director of nursing and other upper management on escalated and hard to staff referrals to get resolution to patient careSubstituted for supervisor in her absence as neededCareCentrix Tampa, Florida (August 2014-March 2016)Escalation Team Lead, Cigna, Florida Blue, Aetna, BCBS Horizon, Centene and CoventryResponsibilities include but not limited to the following:Managed payer, provider and patient complaint resolution.Supported supervisors on escalated calls, 2ndpoint of contact.Worked with supervisors and staff employees to drive efficient call volume activity and management.Created/performed audits for external customers and report on findingsDaily reporting on patient related cases and patient case updates.Supported cross-functional processed for improvement efforts.Kept abreast of technological and industry developmentsCompleted daily report i.e. TAT; Cart; and ESP NINJA TEAM to monitor and audit cases for progress of daily percentage and metrics for projection of incoming case and staffing needWorked with supervisors to create efficient work plans and daily assignments.Completed team/individual production and progression of staffing/ attended calls to discuss staffing needsMonitored and reassigned the work from Que manager for the ESP teamParticipated in special projects; and completed task in timely mannerCreated Excel Powerpoint reports for Human Resource, and or provider related communications to supervisor;Performed real time one on one coaching on desk level process and proceduresMonitored staffing production hours and business needs for work loadFacility Intake Discharge/ECINS and FaxesTeam Lead - Solutions - Call Center (February 2013-August 2014)Responsibilities included but were not limited to the following:Worked with Supervisor to ensure service level metrics are achieved through regular scheduled and just-in-time coaching (Ulysses methodology).Communicated effectively with provides to ensure patients health expectations are met.Worked with team leads and staff employees to drive efficient call volume activity and management through communication with the Workforce Management Team and call queue monitoring.Supported cross-functional process improvement efforts.Kept abreast of technological and industry developmentsProvided training and coachingRewarded and recognized associates monthly for performance above and beyond expectations.Created training tools to ensure that all company policies are being adhereRotation weekend staffing leadCoordinator-Utilization Review Care Verifications (March 2011-February 2013)Responsibilities included but were not limited to the following:Worked as Intake, faxes, Ecins back up when requested.Communicated effectively with provides to ensure patients health expectations are met.Effectively communicated with Managers, Supervisors and Team leads.Benefit verification knowledge such as out of pocket, in/out of network and policy provisions and limitations and process authorizations for services requested.Experience with CareCentrix software, Navinet, Availity, BCBS, Ecins; third party payersExperience with ICD-9/10 Coding Recognition and CPT relating knowledge with medical terminology.Provided authorization based on health plan decisions and UM guidelines when no precertification is required/ obtain authorization when elevation to HP is required.Identified potential payer sources, verify benefits, and obtain initial authorizations.Provided solutions to escalated issues and resolution to reduce repeat of the issue.Worked as Intake, faxes, Ecins back up when requested.Participated in special projects and perform other duties assigned.Took on lead roles and training to co-workers when requested.Patient Referral Intake Customer Solution /Utilization Review Coordinator (August 2010-March 2011)Responsibilities include but not limited to the following:Took referral incoming calls and portal processTrained new associates on Intake proceduresReviewed patient insurance informationReviewed policy guideline and carve outs to ensure patient services are within coverage limitationsCoordinated covered services based on health plan of patients services with Discharge planners as well as providerProvided excellent customer services to patients and providersReviewed all departments information for accuracy prior to staffing cases.Completed faxes and ECINS facility portal as assignedCommunicated with Referral source; patients and MD officesWorked with upper management on projectsEDUCATIONCareCentrix 2010-2017Leadership skill classesDiversity in the work placeChanges in the work placeUlysses trainedURAC trainedPhoenix of Arizona 2010Phoenix, Arizona, United StatesAdministration Health ManagementRicard J Daily 2003Chicago Illinois, United StatesPsychology/NursingA.M.A Medical Billing School 1999Chicago, Illinois, United StatesMedical BillingMedical billing/CollectionCodingCertificateDennells Nursing Assistant 1989Chicago, Illinois, United StatesBasic Nursing SkillsCertificateRichards Vocational 1984Chicago, Il, United StatesGeneral Business DiplomaHigh school diplomaReferencesAvailable upon request |
