Alicia Rosa
Bronx,NY
Summary
Aspiration to apply comprehensive knowledge in Utilization and Case Management to maximize earned revenue while maintaining strict compliance with Managed Care Plans and Regulatory Guidelines
Overview
15
15
years of professional experience
1
1
Certification
Work History
Assistant Coordinating Manager
NYC Health + Hospital: Case/Utilization Management Dept. Jacobi Medical Center, Bronx NY North Central Bronx Hospital
01.2011 - Current
- Provide administrative support to case management team for both North Central Bronx Hospital & Jacobi Medical Center.
- Perform high volume of data entry into EPIC and case management systems.
- Communicate time sensitive correspondences to RN case managers, finance, and the insurance companies.
- Obtain and enter health plan determinations (approvals/denials) on all hospital admissions.
- Communicate adverse determinations to case manager to facilitate Peer to Peer and/or formal appeal.
- Provide health plans with discharge dates on the end-of-day reports to facilitate determinations.
- Direct and communicate urgent reconsideration referrals organized by nurses and physicians, by coordinating documentation for appealing of denied cases within a timely manner.
- Generate forms and letters of all insurance denials to Utilization Review Department and Case management nurses to request external & physician adviser review.
- Contact health plans to validate review determinations; ask questions regarding appeals & MD peer review contacts; and other queries related to utilization management.
- Complete and submit EPIC utilization review of mom-baby birth statistics, and discharge dates to health plans.
- Responsible for ensuring all documentation are provided within guidelines to meet all hospital/insurance standards. This includes: admission, concurrent, discharge and retrospective reviews.
- Ensure timely communication of all Quality Improvement Organizations (IPRO, LAVANTA etc.) correspondences with respective departments.
- Participate in departmental performance improvement initiatives related to utilization management and/or clinical review coordination with care management team, in collaboration with health plans.
- Manage high volume of mail & fax correspondences.
- Communicate insurance eligibility concerns to patient accounts to verify, notify, and update systems.
- Responsible for overseeing all school interns and volunteers including - request, training, supervising and completing all end of internship/volunteer evaluations.
- Validate all utilization reviews are successfully transmitted to payors to avoid Lack of Information denials.
- 2006-2011: Clerical Associate level III
Education
Bachelor of Arts - Psychology
Ashford University
01.2018
Skills
- Microsoft Office Suite proficiency
- Medical coding systems knowledge
- Patient service delivery expertise
- Care management tools proficiency
- Electronic health records systems experience
- Understanding of patient rights laws
- Familiarity with insurance plans and policies
- Data entry accuracy skills
- Conflict resolution mediation expertise
- Healthcare customer service excellence
- Task prioritization effectiveness
- Adaptability to new processes
- Dependable, self-sufficient worker
- Availability for diverse work schedules
Certification
- Evidence Based Stress Reduction Techniques, 2019, Certified by Jen Tex Training & Consulting, LLC
- LEAN Certification Bronze Level, 2014 Administered by NYCHHC
Languages
Spanish
Limited Working
Affiliations
- National Honors Society at Tau Upsilon Alpha (TAU)
- Association for Psychological Science
Timeline
Assistant Coordinating Manager
NYC Health + Hospital: Case/Utilization Management Dept. Jacobi Medical Center, Bronx NY North Central Bronx Hospital
01.2011 - Current
Bachelor of Arts - Psychology
Ashford University