April Granger

• Analyzed complex medical claims to ensure compliance with regulatory standards and internal policies.
• Collaborated with healthcare providers to resolve discrepancies and improve claims processing efficiency.
• Reviewed and interpreted clinical documentation to validate claim accuracy and appropriateness of services billed.
• Conduct comprehensive screening and preparation of case files, ensuring all relevant medical records are organized and ready for nurse review, including verification of CPT codes, assessment of medical necessity, and identification of potential cost‑saving opportunities.
• Request medical records from healthcare providers to support medical review processes, utilizing mail or fax communication based on each provider’s stated preference.

• Support the coordination of medical services by managing intake, performing initial screenings, and assisting with the implementation of care plans to promote appropriate utilization of healthcare resources.
• Respond to incoming calls from physicians, providers, and members to determine precertification requirements for outpatient services, using CPT‑4 and ICD‑9 codes to ensure accurate authorization.
• Maintain and complete weekly operational reports using Excel spreadsheets, ensuring accuracy, consistency, and timely submission.
• Train new hires on the precertification process, including instruction on Aetna/CVS systems, departmental policies, and standard operating procedures to support successful onboarding.
• Manage intake for out‑of‑country emergency inpatient stays and assign cases to the next available nurse to ensure timely and effective case management.
• Make outgoing calls to hospitals to verify member discharge information and ensure accurate coordination of post‑discharge services.

• Communicate with physicians, hospitals, and providers to confirm approved services in accordance with the member’s benefit plan.

• Apply medical policies and clinical guidelines to make appropriate coverage determinations for unique or complex cases.

• Perform non‑clinical research, including eligibility verification, coordination of benefits (COB), and benefit verification to support accurate decision‑making.

• Maintain accurate, thorough, and timely documentation of all activities within the E.Tumes system.

• Perform referral maintenance as needed to ensure proper routing and continuity of care.