Zauna Noil
Customer Service
Fredericksburg,VA
Summary
Over 15+ years of Professional healthcare experience Managed Care background with 6+ years of HEDIS experience Excellent interpersonal, communication and organizational skills Prior Authorization/Insurance follow-up 15+ years of Medicaid, Medicare, MC, and Commercial Computer proficient with Kofax, e-fax, Microsoft Outlook, and Excel, typing 50+WPM
Overview
16
16
years of professional experience
1
1
Certification
Work History
Utilization Management Coordinator
Centene, Superior Health Services
06.2023 - Current
- Under the direction of the Manager of UM Operations, the Utilization duties: :Coordinator triages all short stay inpatient admission requests to the appropriate inpatient review nurse and performs data entry into the CCMS and MedHOK systems
- Coordinator also monitors and resolves pending events. Enter data hospital occurrences, information from the hospital or extended care facility into CCMS and/or MHK
- Verbally communicating to the requesting facility of the inpatient notification number.
- Responsible for working reports, daily logs and the end of month reconciliation process as assigned for the delegated provider units essential functions.
- Receive information by telephone or fax from physicians and hospitals regarding inpatient admissions. · Obtain required information from the caller and perform data entry into the system according to department documentation standards following department’s guidelines.
- Generate and process daily designated reports, letters, delegated discharge logs and workload. Process Out of Network Forms and update events as necessary.
- Monitor generated reports to ensure timely turn around and decisions. Coordinate with Care Management to ensure that the inpatient admission is immediately conveyed in order to update the admission record in a timely manner.
- Works closely with the Clinician staff to coordinate the month end reconciliation process and day to day resolution of pending cases.
- Participates in department projects and special assignments for cross-coverage purposes to meet strict daily processing deadlines.
- Assists with the documentation of workflows and procedures and cross-trains co-workers as needed. Attends scheduled meetings, training sessions in both classroom and computer-based required training sessions
- ·Performs additional THP related duties as assigned by UM Ops Management
- Maintains a current procedure manual as changes occur.
Quality Improvement Specialist
Centene Health Remote
11.2022 - 05.2023
- External)
- Data reporting needs, HEDIS abstraction, clinical research
- Reviewed facility/professional medical claims for correct diagnosis, patient information
- Maintain data collection, data entry, tracking and generate reports
- Medical record collection, HEDIS project, study analysis, follow NCQA Standard, HIPAA regulations
- Contact physician sites, provider search, Texas Department of Health Records
- Design, run, manage the data review process to ensure accuracy and integrity of data reporting.
Benefits/Authorizations Specialist
Lucid Lane Remote
06.2022 - 09.2022
- Ensured timely and accurate insurance authorization are in place prior to authorization services are rendered
- Updated medical records to insurance carriers to expedite prior authorization processes
- Look through denials and submit appeals in a bid to get them approval from insurance companies
- Research managed care, worker’s compensation accounts, and updated patient’s account
- Updated member demographic information, managed correspondence with insurance companies, internal staff, and specialists as needed
- Prepared patients for virtual appointments.
Remote HEDIS Coordinator
Anthem, BCBS
01.2022 - 05.2022
- Handled calls from providers, doctor’s office, and members
- Reviewed records and uploaded to patient’s account
- Transferred records to PDF form
- Updated metrics/benchmarks for each measure
- Measures encountered included: HBP, Diabetes, Well Baby, Adult Well Visits, Medicare
- Immunizations, and others
- Handled 65+ calls daily via multiline phone system to providers
- Placed follow-up calls to providers for missing or incomplete information
- Utilized dual monitors
- Filed, faxed, scanned, and uploaded documents
- Scheduled medical records charts review for HEDIS
- Carefully correct all medical charts received
- Ensure each chart is label correctly before uploading them into the system
- Maintained HIPAA regulations.
Patient Support Services Representative
Conifer Health Solutions
04.2021 - 08.2021
- Processes requests for medical records, sends medical records to insurance companies, attorneys office
- Called managed care, commercial, workers compensation, government managed insurance companies to verify eligibility
- Mailed and submitted a hard copy 1500 forms, EOB’s, UB92’s, and itemized statements to designated business unit contact.
Benefits Specialist
Addison Group/Veterans Services
06.2020 - 08.2020
- Coordinated with traveling providers to conduct examinations in high volume areas, and notify veterans if providers call to reschedule
- Added and removed provider block times into OMS when necessary
- Daily check and schedule cases that are assigned to the Pending Follow-Up Schedule Status.
Substitute Teacher
Humble Classical Academy
10.2019 - 06.2020
Authorizations Specialist
Bridgeway Center Inc
04.2014 - 10.2017
- Obtained prior authorizations for third party payers such as Tricare, Champ VA, workers compensation
- Collaborated with government managed care insurance, worker’s compensation insurance managed care, and providers requesting authorizations for outpatient treatment reports, medication management clinical forms for all insurance groups
- Documented specific details related to the authorization including approval number, valid dates, and number of visits
- Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed
- Successfully worked with payers via electronic/telephonic and or/fax communication
HEDIS Coordinator
Mednax Medical Group
09.2007 - 09.2012
- Prepared medical records for HEDIS audit, attorneys, patients, and insurance companies
- Scheduled a variety of appointments, and called and verified all managed care, commercial, government insurance
- Secured documentation from medical providers, insurance companies, and patients, and accurately updated pending claims with new information
- Obtained medical bills, entered charges in system, and medical records from EMR/EPIC system scanned and mailed to insurance companies for processing
- Processed medical records via to hospitals and other providers by fax, phone, and electronically.
Education
Bachelor of Arts - Healthcare Administration
University of Phoenix
Smyrna, GASkills
- Patient Admission
- Intramuscular Injections
- Compliance Issues
- Medical Supply Management
- Billing Codes
- System Updates
- Rate, Rule and Regulation Updating
- Client Inquiries
Certification
- CMA - Certified Medical Assistant
- First Aid/CPR Certified
- Certified X-ray Technician
Timeline
Utilization Management Coordinator
Centene, Superior Health Services
06.2023 - Current
Quality Improvement Specialist
Centene Health Remote
11.2022 - 05.2023
Benefits/Authorizations Specialist
Lucid Lane Remote
06.2022 - 09.2022
Remote HEDIS Coordinator
Anthem, BCBS
01.2022 - 05.2022
Patient Support Services Representative
Conifer Health Solutions
04.2021 - 08.2021
Benefits Specialist
Addison Group/Veterans Services
06.2020 - 08.2020
Substitute Teacher
Humble Classical Academy
10.2019 - 06.2020
Authorizations Specialist
Bridgeway Center Inc
04.2014 - 10.2017
HEDIS Coordinator
Mednax Medical Group
09.2007 - 09.2012
Bachelor of Arts - Healthcare Administration
University of Phoenix
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