Delana Santos

Clinical Administrative Coordinator with experience in referrals, prior authorizations, medical necessity reviews, claims processing, and protected health information. Skilled in CareWeb QI/MCG, EZ-Cap, Excel, provider and member communication, document handling, and accurate administrative workflows. Brings more than 10 years of administrative office experience and medical billing and coding training.

Clinical Administrative Coordinator - OptumCare Network - WA Region

(2020-10)

• Manage incoming and outgoing referrals and prior authorizations for clinical services.
• Conduct medical necessity reviews and prepare cases for clinic teams.
• Use CareWeb QI/MCG to support medical necessity determination workflows.
• Review fax requests and identify information needed for medical and clinical services.
• Coordinate calls with providers and members regarding services, benefits, and clinical needs.
• Communicate clear, accurate clinical information to utilization management nurses and medical directors.
• Support timely compliance by organizing case information and coordinating follow-up across departments.

Administrative Claims Assistant - Northwest Physicians Network

(2014-08 - 2019-06)

• Sorted, date-stamped, and logged incoming mail for delivery to appropriate departments.
• Recorded refund checks in Excel spreadsheets to maintain accurate financial records.
• Entered claim pricing into the EZ-Cap system for accurate claims processing.
• Processed Humana hospital claims and organized supporting documentation.
• Sorted and filed claims while maintaining organized paper records.
• Returned paper claims that lacked required medical documentation.
• Secured cabinets containing protected health information at the end of each workday.

Certification - Medical Billing and Coding - Pierce College