Amanda Morales

• Develops and maintains current knowledge of state and federal regulatory requirements related to all aspects of grievances and appeals for Medicare managed care organizations, Medicaid, home health care, managed long term care as well as contractual requirements.
• Triage all new incoming appeals and grievances and distinguish between an Appeal or Grievance and address accordingly.
• Created cases for Expedited appeals or grievance. Ensure the case is reviewed within the allotted 72 hour timeframe.
• Consult with the member, family members, providers and health plan departments as necessary.
• Verified member information by analyzing existing evidence on file.
• Investigate and coordinate the resolution of routine and complex grievances and appeals according to defined processes and procedures ensuring that required time frames and regulatory requirements are met. accurate and timely follow up is completed and activities are documented as required.
• Conducts review of requests for prior authorizations health services, as required in certain product lines and prepares written responses consistent with regulatory requirements.
• Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure proper appeal resolution and execution of the plan's responsibilities.
• Acted as a departmental resource on appeals and grievance matters.
• Created, composed and maintained appeal response templates.
• Consult with enrollees, providers and medical director as needed.
• Coordinated with other departments to compose appeal responses.
• Developed appeals functions, policies and procedures and documentation.
• Review and reprocessed out of network provider claims if warranted.
• Communicate verbal and written notifications of overturned or upheld decisions to providers or members within the allotted time frame.

Coordinated communication to plans other departments to ensure access to care and contract configuration for all letters and agreements for out of network providers.

Handled all daily phone queries from all provider types regarding but not limited to such issues s resolution of provider complaints and plan policies and procedures, claim inquires.

Responsible for contracting with Ancillary Providers, manage provider demographics information changes (tax identification numbers, new addresses ect.) Submitted weekly progress reports.

Develop strong interpersonal relationships with providers so there is an enhanced partnership with providers.

Resource for routine information and coordinator/liaison for researching provider questions and communication of findings back to providers.

• Implemented and documented utilization review activities which incorporate a thorough understanding and application of InterQual managed care guidelines, clinical knowledge and understanding of timeliness and appropriateness of medical services related to effective cist containment.
• Prepared all required reports in appropriate format and submit in a timely manner, including statistical computations and in depth data analysis.
• Provided accurate, comprehensive and pertinent utilization data and information to the Utilization Management Committee.
• Maintained up to date records at all times.
• Properly directed inbound calls in phone queues to improve call flow.
• Established and maintained effective communication with staff, physicians and community organizations to promote high quality patient care.
• Operated and managed multiple phone line call center.

• Ensured all information received related to appeals or grievances are stamped and logged into Access Program.
• Utilized indicated techniques/procedures in order to obtain medical necessity information to support required services, i.e. contact with treating physicians, hospital records, pharmacy records.
• Reprocessed and corrected any professional claims that were overturned and approved on appeal/grievances.
• Prepared all medical records and clinical notes required for medical review and needed to make all determinations of appeal or grievances.
• Communicated verbal and written notifications of overturned or upheld decisions to providers or members within the 45 day allotted time frame.
• Abiding by HIPPA regulations and confidentiality requirements, document, research and review member complaints, involving quality of careof service with appropriate clinical and/or other department stuff

• Coached employees through day-to-day work and complex problems.
• Responded to customer inquiries and resolved complaints to establish trust and increase satisfaction.
• Developed and maintained strong relationships with customers to maintain loyalty and satisfaction.
• Conducted training and mentored team members to promote productivity and commitment to friendly service.
• Managed a team of customer service representatives.
• Monitored services staff for quality assurance.
• Reprocessed and corrected professional claims that were processed incorrectly.
• Answered all escalated provider or member calls regarding claim issues.
• Assisted with the member service queue calls
• Conducted orientation for both members and physicians to Atlantis policy and procedures. Operated and managed multiple phone line call center.
• Generated weekly time sheets and payroll.
• Assisted the Director of Operations with escalation issues.
• Interviewing (hiring), staff evaluations, on the job training for new hires.
• Participated in monthly meetings as required.
• Assisted other departments as needed (claims, utilization management).
• Created and maintained databases, spreadsheets and files.
• Answered and assisted with any questions regarding service, procedures and policies.
• Created, prepared, and delivered reports to various departments.
• Led regular customer service meetings to review progress identify challenges and provide feedback.