Angela Coles

• Participate with Interdisciplinary teams to locate and coordinate care services and resources.
• Perform timely outreaches to members and providers to implement coordination of care, close care gaps and to produce provisions of services.
• Conduct assessments, surveys and screenings for appropriate action such as for care/service satisfaction initiatives as well as to identify specific care coordination needs.
• Engage in continuous trainings to expand skill sets and remain competent with knowledge and competencies within healthcare/company industry roles as well as with departmental care management requirements.
• Managed patient caseloads effectively, ensuring timely follow-up and appropriate interventions.
• Built strong relationships with clients to deliver emotional support and companionship.

• Contacts insurance companies to determine patients' eligibility and coverage for hospital admission
• Contacts pre-certification companies to initiate pre-certification and obtain approval of confinement
• Works closely with Financial Counselors in evaluating patients' insurance coverage
• Documents appropriate information regarding benefits to be received by hospitals, and the subsequent financial responsibility of clients
• Reviews admission documents/information to ensure accuracy
• Ensured compliance with HIPAA regulations while managing sensitive patient information during the verification process.

• Assisted with prior authorizations requests via fax and email and manage the referral process
• Processed out of network requests for consideration of in network level benefits
• Verified appropriate ICD 10 and CPT coding usage
• Communicated determinations to providers within Medicare time frames
• Processed approval letters within Medicare time frames
• Enhanced operational workflows by maintaining well-organized documentation systems and updating records accurately as needed.

• Improved patient care management by efficiently coordinating and monitoring medical services.
• Presented findings from utilization reviews to leadership teams, informing data-driven decision-making on resource allocation initiatives.
• Proactively identified potential barriers to effective service delivery, working closely with clinical teams to address issues before they impacted patient outcomes.
• Conducted thorough reviews of medical records, ensuring compliance with regulatory requirements and industry standards.
• Increased overall efficiency by streamlining authorization processes for medical procedures.
• Managed approximately 40 incoming calls, emails and faxes per day from customers.

Accessed index system to review incoming clinical faxes

• Reviewed clinical faxes from providers and facilities for accuracy and completeness
• Provided clinical faxes of the Utilization Management Clinical staff for precertification
• Prepared faxes for nurses to determine if the case should be approved or denied
• Coordinated inpatient discharge dates for billing purposes by following department processes
• Managed 30 incoming calls or incoming post services
• Referred cases requiring clinical review to a Nurse reviewer
• Responded to telephone and written inquiries from clients, providers and in house departments

• Responsible for contacting medical facilities in reference to medical reviews
• Retrieved member data base on the types of medical services rendered
• Scheduled delivering of medical charts based on predetermined timelines
• Consistently meet call center performance metrics based on outbound calls and scheduled charts