Experience

Humana

• United States
• Insurance
• 700 & Above Employee

• Utilization Management Supervisor

  • May 2014 - Present

  Supervised 16 member team managing daily operations, documentation, and communication of inpatient medical services and authorization determinations. Coached, developed and motivated team members with continuing education, meeting target goals and improved team member recognition. Applied clinical knowledge, communication and independent critical thinking skills towards interpreting criteria, compliance and regional policies in creating workflow procedures. Coordinated team schedules, provider communication, leadership discussions, and overseeing our regional customer service line. Job Accomplishments • Improved data accuracy 30% by implementing actions for team performance and process improvement providing associate engagement activities and policy updates weekly • Developed and standardized forms to create efficiency and reduce turnaround time in obtaining authorizations increasing production in last year by 15% over previous year • Reported trends and develop recommendations for utilizing staff in the most efficient and effective manner, increasing production in last year by 15% over previous year • Maintained operating budget under goal and reduced overtime 45% by analyzing trends and adjusting scheduled to fulfill the business need • Earned two STAR awards for going above and beyond scope to benefit the organization managing and specialist team of up to 35 non-clinical associates and taking on a new division to manage • Collaborated with health care facilities in communicating medical services against established Medicare Guidelines to facilitate optimal care and treatment • Worked together with Utilization Management clinical teams for coordination of care for members, fulfilling departmental regulatory actions and ensuring compliance with HIPAA regulations Show less



Carolina Medical Center

• Textile Manufacturing
• 1 - 100 Employee

• Medical Benefit Payor Specialist

  • Sep 2008 - Sep 2014

  Coordinated insurance authorizations for inpatient, outpatient, medication management and therapy services for multiple departments. Documented pre-certification benefits in IDX, McKesson & Star Navigation systems. Collaborated with clinical staff to obtain necessary information for Healthcare Management Companies including Blue Cross Blue Shield, Aetna, Cigna, Med Cost, and United Healthcare Extensive knowledge of COB (coordination of benefits) rules, MSP regulations, Medicaid policies and categories. Documented Medicaid and Managed Care services for claims and denial reviews Job Accomplishments • Initiated a process to track visits, pre-certifications and denials for medication clinic and outpatient therapy patients used for monitoring data to implement a new procedure to ensure prior authorizations were received and eliminating denials • Improved and designed operational procedures for insurance verification, authorizations and claims by working with multiple departments to improve processes and program tools • Worked registration desk for the Emergency Room Show less



CACTX

• Assistant Operations Manager

  • Aug 2005 - Sep 2008

  • Managed cost analysis, accounts receivables and accounts payable ledgers • Processing of payroll • Preparation of customer proposals • Produced and kept departmental employee records • Report generation and updated implementation of procedures • Scheduling and supervision of staff • Published monthly newsletter content and updated company website • Managed cost analysis, accounts receivables and accounts payable ledgers • Processing of payroll • Preparation of customer proposals • Produced and kept departmental employee records • Report generation and updated implementation of procedures • Scheduling and supervision of staff • Published monthly newsletter content and updated company website