Case Management Coordinator - CVS/AETNA
(2023-04)
- Using a holistic approach consults with case managers, supervisors, Medical Directors, and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review to achieve optimal outcomes.
- Coordinates and implements assigned care.
- Plan activities and monitor care plan progress.
- Identifies high-risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate.
Utilization Management Rep II - BEACON HEALTH OPTIONS
(2022-07 - 2023-04)
- Manage incoming calls, including triage, opening of cases, and authorizing sessions.
- Interprets policies and clinical guidelines.
- Conducts clinical screening.
- Determined contact and benefit eligibility; provided authorization for inpatient admissions, outpatient pre-certifications, prior authorization, and post-service requests.
- Kept up with compliance requirements and amendments to market contracts specific to care management requirements.
Claim Analyst - DEPT. OF AGING & REHAB SERVICES
(2016-09 - 2022-08)
- Independently reviewed and evaluated applicant's eligibility for Social Security disability benefits.
- Analyzed and evaluated compliance monitoring policies and guidelines designated by federal guidelines and SOPS set forth for evaluation of claims.
- Gathered, reviewed, and analyzed large volumes of records
- Kept up with compliance requirements and amendments to SOPs specific to listing requirements for federal and state QA reviews.
- Maintained a quality review rating of 98.8 by resolving any issues and concerns from external and internal auditors.
Mental Health Support Worker - HALL COMMUNITY SERVICES
(2008-09 - 2018-05)
- Facilitated care coordination with other service providers to enlist existing supports in determining and meeting service objectives.
- Provided direct clinical services to clients
- Utilized Lauris (Electronic Medical Record system) and other web-based software for all clinical documentation, record keeping, and coordination.
- Coordinated with operations management to ensure that we were following market specific contractual requirements set forth including local, federal and state government regulations.
- Met with team monthly to go over compliance issues if any and how to work to resolve these issues.
- Kept in contact with compliance officers to ensure all contractual regulations were being met.
