Carla M Smith

• Review, evaluate, and approve/deny contracting applications.
• Investigate credit, criminal, and financial reports for fraud detection.
• Conduct monthly licensing and education audits.
• Build agent contracts in licensing systems.
• Update agent profile changes in various licensing systems
• Network, Build, and Maintain relationships with licensing agents and insurance corporations
• Communicate and respond to business partner prospects to determine if licensing agent applicant is eligible to partner with Insurance Group(s)
• Terminate agent contracts
• Consistent task management exceeding 98th percentile over a 4-week rolling average.
• Daily administrative routines - Data entry, Reporting, File Management
• Current with continuous 48, AK & HI state laws and licensing requirements to ensure an accurate and efficient review process.
• Engagement - Weekly interactive team ideation and engagement meetings
• Customer facing communication and professional writings

• Matched clients to open positions based on skills and work requirements.
• Build events in Case Management Systems.
• Generate and mail response communication to customers.
• Schedule, coordinate and lead (group or individual) reemployment programs; i.e., orientations, assessments and workshops.
• Conduct weekly customer profile process reviews to determine transfers, eligibility and execute as appropriate.
• Appointment scheduling
• Resume Reviews and Interview preparation with customers
• Search and send job recommendations to customers.
• Recruit customers to attend weekly Job fairs and onsite job interviews.
• Comprehensive interview and assessment process to develop an Individual Reemployment Plan (IRP).
• Review, promote and refer all qualifying customers to program match(es).
• Review Labor Market Information (LMI) and TORQ results with customers.
• Record all pertinent data related to all RES programs in the Case Management System.
• Maintain all excel spreadsheets and/or other documents.
• Submit the Failed to Participate (FTP) and Re-qualification documentation to Department of Workforce Development.
• Correct any service entry or reporting errors
• Refer customers to appropriate partner programs for additional services when deemed necessary.
• Conduct follow up and 45 day program completion audit review.
• Audit team performance and prepare evaluations.
• Train and mentor new staff.
• Demonstrated sound time management and project management skills by effectively and efficiently organizing, prioritizing and completing multiple assignments in a timely manner.
• Proficient with Microsoft Suite tools and Internet Navigation skills.

• Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review).
• Monitor RCP program for the state of Indiana.

Audit weekly and monthly member activity.

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  Review members claims to determine if they are abusing and overusing health benefits.
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  Investigate if members are involved in fraud and drug abuse.
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  Restrict members access to certain health services provided by state insurance.

Authorize members and doctors request for health and referral services.
Report member to FSSA for violation of services.

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  Provide members with counseling and education and intervention options.
  Prepare weekly reports for daily compliance meetings.
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  Research fraud and abuse claims and report to the state.
  
• Conducts initial review of files to determine appropriate action required. Maintains and updates tracking databases.
• Responds to requests, calls or correspondence within scope.
• Acts as liaison between medical management operations and other internal departments to support ease of administration of medical benefits. May assist with case referral process.
• May collaborate with external community-based organizations to facilitate and coordinate care under the direction of an RN Case Manager.
• Educate members on use of ER and doctor office visits.
• Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.
• Handle member calls for Value Added Benefits.
• Prepare weekly spreadsheets, track, and load to SharePoint.
• Perform doctor searches for members and case managers.
• Community Health Worker certified
• Complete members' authorizations for medical services.
• Assist members with community resources.
• Connect members to Case Managers and Community Health Workers in their area to assist with health needs.
• Assist Medicaid and HIP members.
• Process authorizations for members procedures.
• Medical coding