Allyson Parker
Overview
21
21
years of professional experience
Work History
Manager - Clinical Appeals
Centene Corporation
06.2024 - Current
- Manages appeal clinical review team and ensures compliance with applicable guidelines, policies, and procedures
- Reviews and analyzes utilization management activities, operations, costs, and forecasted data to identify areas for improvement within Utilization Management (UM) to align to goals and objectives
- Develops, implements, and maintains compliance with applicable guidelines, policies, and procedures
- Reviews reports to identify trends and areas of improvement and provide recommendations to senior leadership
- Maintains knowledge of processes, regulations, accreditation standards, and industry best practices related to Utilization Management
- Educates and provides resources for clinical appeal reviewers on key initiatives and to facilitate on-going communication between utilization management department, members, and providers
- Works with the senior management team to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services based on State/Federal Regulations and evidence-based clinical practice.
- Provides coaching and guidance to clinical appeal team to ensure adherence to quality and performance standards
- Assists with onboarding, hiring, and training clinical appeal reviewers
- Leads and champions change within scope of responsibility
- Health Net
Lead Clinical Review Clinician - Appeals
Centene Corporation
04.2022 - 06.2024
- Subject Matter Expert for Physical Health medical authorizations: Medical and Pharmacy authorization appeals, External Medical Review/State Fair Hearing, and Complaints. Experience in clinical review for Physical/Occupational/Speech Therapy and Long-Term Support Services (LTSS) 1 appeals.
- Provide education and clinical nursing knowledge support to clinicians, members/providers, Medical Directors, and stakeholders regarding clinical review, policy, work process, and regulatory compliance.
- Review regulatory/contractual language to update work processes for alignment and efficiency.
- Complete internal team clinical review audits to determine educational needs and gaps in work process, policy application, and regulatory compliance.
- Collaborate with management in Performance Improvement: develop and implement a performance improvement plan, provide individualized education/coaching, and reassessment of performance.
- Collaborate with management to review and plan re-allocation of clinical versus non-clinical work process components to maximize staff productivity.
- Support Management with preparing compliance reporting (ex: daily TAT, Out of TAT) and investigating root cause and developing plan of action.
- Identifying, researching, and reporting trends to Leadership and Medical Directors regarding Prior Auth denials that lead to higher frequency of appeals for Level 1 and EMR/Fair Hearing appeal reviews.
- Participate in stakeholder discussions to provide in-depth data that facilitate clarification and/or implementation of policy and regulations.
- Initiate and facilitate cross-team communication for improved workflow and appeal review processing with UM Prior Auth teams, Medical Directors, and Claims to clarify clinical review, application of policy and regulations to authorizations.
- Collaboration with Case Management and Service Coordination for outreach to members during appeal review to facilitate submission of supporting documentation for requested services or after appeal to facilitate assistance with current or ongoing medical needs related to the requested services.
- Training and Mentorship of New Hires. Training of Tenured staff to new or updated Level 1 appeal work processes and External Medical Review/State Fair Hearing processing.
- Consistently meet and exceed expectations for corporate productivity goals, regulatory compliance, and appeal Turn-around-Time (TAT). Ensure daily team productivity and regulatory TAT compliance.
- Superior HealthPlan
- February 2024 PHCO Employee of the Month: Trusted Partnerships
Clinical Appeal Review Clinician and State Fair Hearing Clinical Coordinator
Centene Corporation
11.2016 - 04.2022
- Prepare clinical review appeal summary for Physical Health authorizations (Medical, Pharmacy, Physical/Occupational/Speech Therapy, and Long-Term Support Service (LTSS).
- Preparation and presentation of State Fair Hearings.
- Clinical investigation, clinical review compilation, and response to Compliance for appeal related Complaints.
- Subject Matter Expert for Physical Health medical authorizations: Medical and Pharmacy authorization appeals, External Medical Review/State Fair Hearing, and Complaints. Experience in clinical review for Physical/Occupational/Speech Therapy and Long-Term Support Services (LTSS) 1 appeals.
- Process creation and updating based on new/updated state or federal regulations and evidence based clinical policy.
- Educate and provide clinical nursing knowledge support to clinicians, providers, and members regarding clinical review, policy, work process, and regulatory compliance.
- Collaboration with Utilization Management Prior Authorization teams, Medical Directors, Claims, Case Management, and Service Coordination to facilitate communication for improved workflow and appeal review processing.
- Training and Mentorship of New Hires. Training of Tenured staff to new or updated Level 1 appeal work processes. Training of tenured staff to State Fair hearing processes.
- Consistently meet and exceed expectations for corporate productivity goals, regulatory compliance, and appeal TAT.
- Compile, review, and present appeal process/clinical review at regulatory audits.
- Back up Team Lead
- Superior HealthPlan
Pediatric Nurse Practitioner - Primary Care
Baylor Scott and White
01.2011 - 11.2016
- Advance Practice Nurse providing outpatient/clinic based primary care to the Central Texas pediatric population to include: Well Child exams and immunizations, Acute/Ill Child exams and medically appropriate care plan, developmental screening (to include ASQ, PSC 17, MCHAT), appropriate referral to Pediatric Subspecialty providers and Speech/Physical/Occupational therapy providers (internal and community providers), care coordination/management as a Primary Medical Home provider for chronic medical diagnoses (to include Allergies/Asthma, Diabetes, Obesity, Cardiac disorders, Genetic disorders)
- General Pediatric provider for the Cranio-Facial multidisciplinary team: General Pediatric assessment and coordination of care (medical and mental health care) for Central Texas pediatric population with diagnoses of Cleft lip/palate, Microtia, and other genetic disorders relating to Cranio-Facial Anomalies.
- McLane Childrens
Adjunct Clinical Faculty
University of Mary Hardin-Baylor
08.2009 - 10.2010
- Clinical instructor for BSN students: Adult Medical/Surgical courses
Part Time/PRN Staff Nurse
King’s Daughter Hospital
12.2008 - 10.2010
- Staff Nurse: Emergency Room and Adult Medical/Surgical
Part Time/PRN Staff Nurse
First Choice Children’s Home Health
06.2005 - 12.2006
- Performed all nursing duties related to specific medical needs of each child in the home setting. To include skin care, tracheostomy and gastrostomy site care, applicable Physical/Occupational Therapy, oral and enteral feeding therapy, medication administration. Provided family and patient education as appropriate/applicable based on individualized care plan.
- Communicated with and between parents, other care givers, and Nursing Director pertaining to patient care plan.
Staff Nurse
Dell Children’s Medical Center of Central Texas
01.2005 - 10.2008
- Pre/Post Surgical Unit: General Medical, Trauma, Surgery – Orthopedic, Urology, Plastic/Reconstructive, Gastrointestinal, HEENT, and Neurological
- Unit representative on Hospital Performance Improvement Committee
- Unit coordinator for Hospital and Joint Commission required audits and training
- Charge Nurse on Day Shift
- Relief Preceptor for New Graduate nurses
Timeline
Manager - Clinical Appeals
Centene Corporation
06.2024 - Current
Lead Clinical Review Clinician - Appeals
Centene Corporation
04.2022 - 06.2024
Clinical Appeal Review Clinician and State Fair Hearing Clinical Coordinator
Centene Corporation
11.2016 - 04.2022
Pediatric Nurse Practitioner - Primary Care
Baylor Scott and White
01.2011 - 11.2016
Adjunct Clinical Faculty
University of Mary Hardin-Baylor
08.2009 - 10.2010
Part Time/PRN Staff Nurse
King’s Daughter Hospital
12.2008 - 10.2010
Part Time/PRN Staff Nurse
First Choice Children’s Home Health
06.2005 - 12.2006
Staff Nurse
Dell Children’s Medical Center of Central Texas
01.2005 - 10.2008