ALICIA RAMBUS
Downers Grove,IL
Summary
Dynamic customer service professional with extensive experience in call center operations, healthcare administration, and disability claim processing. Expertise in utilization management and insurance pre-authorizations, complemented by a proven ability to manage high-volume inquiries and resolve complex issues while ensuring compliance with regulatory standards. Proficient in Microsoft Word, Excel, Epic, and the Genesys phone system, consistently delivering accurate documentation and optimizing workflow management for enhanced operational efficiency. Committed to fostering positive client relationships and driving organizational success through exceptional service delivery.
Overview
22
22
years of professional experience
Work History
Utilization Management Administration Coordinator II
Humana
Remote, IL
01.2019 - Current
- Facilitated non-clinical support operations for nursing team efficiency.
- Manage fax attachments, incoming calls, and timely responses to department phone line inquiries.
- Managed outbound communication to gather clinical data for RN evaluations. Established new cases for member tracking. Coordinated with facilities to retrieve discharge information for member status updates.
Referral Specialist II
AIM Specialty Health
Westchester, IL
01.2015 - 01.2018
- Oversaw clinical referral processes to ensure timely pre-authorization and compliance with regulations.
- Assessed member eligibility and demographics while facilitating pre-authorizations for radiology services.
- Analyzed referral requests to confirm all essential elements, such as codes, place of service, service type, provider identity, and complete medical information, are prepared for insurance submission.
- Applied comprehensive knowledge of ICD-10 and CPT coding to ensure accurate and clear communication with healthcare professionals.
Claims Specialist
MetLife Disability
Remote
01.2004 - 01.2015
- Evaluated and processed disability claims, ensuring alignment with plan provisions and regulatory standards.
- Evaluated and confirmed eligibility status for disability and family medical leave requests to ensure regulatory adherence.
- Collaborated with team members to support assigned accounts, meeting quality assurance standards and client expectations.
- Coordinated interactions among claimants, employers, healthcare providers, and attorneys to ensure efficient resolution of claims.
- Assessed benefits eligibility and executed pay claims with precision and efficiency.
- Provided mentorship to new hires, fostering skill development and confidence in their roles.
Education
High School Diploma -
Carl Schurz High School
ChicagoSkills
- Strong organizational skills
- Eligibility determination
- Efficient prior authorization management
- Teamwork
- Time management
- Problem-solving
- Document review
- Customer service
SUMMARY OF QUALIFICATIONS
- Proven track record of effectively managing patient and provider communications.
- Demonstrated track record of consistently meeting and exceeding performance expectations.
- Skilled in navigating hospital electronic medical records (EMR) systems to ensure accurate documentation and streamlined workflow.
- Adept at handling complex cases with discretion and empathy.
- Committed to delivering high-quality service in a fast-paced, compliance driven environment.
Timeline
Utilization Management Administration Coordinator II
Humana
01.2019 - Current
Referral Specialist II
AIM Specialty Health
01.2015 - 01.2018
Claims Specialist
MetLife Disability
01.2004 - 01.2015
High School Diploma -
Carl Schurz High School