CAROLYN N. JONES
Citrus heights,CA
Summary
Dedicated and results oriented professional with a proven track record in customer service, medical management, utilization review and referral specialist roles. Adept at seamlessly navigating complex healthcare systems, optimizing patient care, and ensuring efficient utilization of resources. Possesses exceptional communication, problem-solving , and interpersonal skills, consistently exceeding in delivering high-quality service and fostering positive relationships with clients and collaborators.
Overview
11
11
years of professional experience
Work History
Medical Management Specialist
Anthem Blue Cross - Elevance Health (Remote)
09.2021 - Current
- Gathers clinical information regarding a case and determines appropriate areas to refer or assign the case to
- Responsibilities exclude conducting any utilization management review activities
- Provides information regarding network providers or general information when requested
- May assist with complex cases
- Notify provider offices of all approval auth requests
- May act as a liaison between medical management and/or Operations and internal departments.
- Enhanced patient care by implementing efficient medical management processes and protocols.
Outreach Specialist/Medicaid National QM Member
Anthem Blue Cross - Elevance Health (Remote)
01.2021 - 09.2021
- Coordinates follow-up care plan needs for the Maternal Child Outreach members by scheduling appointments or enrolling members in programs by utilizing numerous websites for resources needed
- Recommends treatment plan modifications and determines need for additional services, in conjunction with case management and provider
- Supports the CA Medicaid line of business through outreach to members out of compliance with Hedis measures, assisting to close gaps in member care.
- Increased community engagement by implementing targeted outreach strategies and regularly participating in relevant events.
- Conducted comprehensive needs assessments to identify gaps in services and develop tailored solutions for diverse populations.
- Developed successful partnerships with local organizations for mutually beneficial collaboration and resource sharing.
- Managed a caseload of clients, providing personalized support and guidance throughout their journey to access vital resources.
Registration Assistant
Dignity Health CLC/DHWS (Hybrid)
10.2019 - 01.2021
- Assist with the course registrations in person and by telephone, verify insurance and process authorizations for breast pumps, schedule parents to NICU CPR classes and other local, state or federally funded programs as needed
- Enhanced customer satisfaction through prompt and accurate assistance during registration.
- Improved patient registration process by streamlining documentation and data entry tasks.
- Generate and distribute enrollment information, documents, and reports for faculty and staff
- Assisted with special projects as assigned by supervisors, contributing valuable input to drive improvements within the department.
- Process refunds and payments for birthing classes, and breast pump rentals
- Answer multi-line phones, route calls to appropriate destinations, answer all questions pertaining to classes being offered as well as new employee orientation, maintain and schedule executive calendar with room requests from all educators, supervisors, and our director within the dept.
Provider Relations Rep
Versant Health
02.2019 - 10.2019
- Enhanced provider satisfaction by addressing and resolving inquiries in a timely manner.
- Strengthened provider networks through regular outreach and relationship building activities.
- Answered provider inquiries via email, telephone and written correspondence.
- Reduced claim disputes by effectively communicating policy changes and updates to providers.
- Streamlined processes for provider credentialing, ensuring accurate documentation and faster onboarding.
- Developed comprehensive training materials for new Provider Relations Representatives, facilitating a smooth transition into their roles.
Referral Specialist/Eligibility Coordinator
Total Med Staffing - Health Net
06.2018 - 01.2019
- Answer inbound calls in a call center environment providing eligibility benefits and claims information to providers and enrollees, in a professional manner daily.
- Streamlined referral processes for increased efficiency, resulting in timely appointments for patients.
- Collaborated with healthcare providers to ensure accurate and complete referral information, improving patient care coordination.
- Managed high-volume referral requests by prioritizing tasks and maintaining organized records.
- Assisted patients in navigating insurance requirements, facilitating approval of necessary treatments.
- Enhanced patient satisfaction by promptly addressing inquiries and resolving issues related to referrals.
Utilization Review Coordinator
Excel Managed Care & Disability Services
11.2017 - 05.2018
- Process all incoming outpatient, worker's compensation and disability referral requests in a timely manner while distributing utilization review determination letters via fax and via email to physician offices, attorneys, claims administrators.
- Enhanced patient care quality by conducting thorough utilization reviews and coordinating with healthcare providers.
- Reduced hospital readmissions by implementing effective discharge planning and ensuring appropriate post-acute care.
- Managed complex cases involving multiple medical conditions, coordinating care among various specialists while adhering to strict timelines for decision making.
- Increased efficiency of the utilization review process through regular communication with insurance companies for timely authorizations.
Inpatient & Outpatient UM Coordinator
River City Medical Group
04.2014 - 10.2017
- Input all inpatient diagnosis and UB codes from incoming hospital face sheets into the system
- Process all inpatient denial, modified and eligibility letters for all Medical Directors
- Ran daily census reports and called hospitals to obtain discharge information to enter in the systems daily
- Schedule follow-up appointments with PCP for patients after hospital discharge
- Process outpatient and inpatient referrals while verifying member's eligibility.
- Increased efficiency by streamlining coordination processes and implementing new organizational systems.
- Managed project timelines for successful completion, ensuring milestones were met and deadlines were adhered to.
Care Coordination Representative
Sutter Health
12.2012 - 04.2014
- Analyze and interpret medical guidelines while making outbound calls to insurance payers
- Identify utilization reviews with missing information or needing correction
- Transmit completed and error-free utilization reviews to the correct designated insurance payers.
- Increased customer satisfaction by addressing and resolving complaints in a timely manner.
- Enhanced company reputation by providing exceptional customer service and support.
Education
Certificate - Medical Assisting
High -Tech Institute
Sacramento, CA01.2012
Skills
- Proficient in MS Office, Teams, Epic, Cerner, Health Connect, ACMP, Aspen, WGS, Member 360, Availity, Salesforce
- Strong Communication Skills, Time Management Skills, Problem Solving and Critical Thinking
- Insurance Verification, Medical Coding and Billing
- Customer Service
- Utilization Review
- Medical Management, Quality Assurance and Hedis Measures
- Utilization Management and Utilization Review
- Electronic Health Record Applications
- HIPAA Compliant
- Organizational Skills and Attention to Detail
References
References available upon request
Timeline
Medical Management Specialist
Anthem Blue Cross - Elevance Health (Remote)
09.2021 - Current
Outreach Specialist/Medicaid National QM Member
Anthem Blue Cross - Elevance Health (Remote)
01.2021 - 09.2021
Registration Assistant
Dignity Health CLC/DHWS (Hybrid)
10.2019 - 01.2021
Provider Relations Rep
Versant Health
02.2019 - 10.2019
Referral Specialist/Eligibility Coordinator
Total Med Staffing - Health Net
06.2018 - 01.2019
Utilization Review Coordinator
Excel Managed Care & Disability Services
11.2017 - 05.2018
Inpatient & Outpatient UM Coordinator
River City Medical Group
04.2014 - 10.2017
Care Coordination Representative
Sutter Health
12.2012 - 04.2014
Certificate - Medical Assisting
High -Tech Institute
Similar Profiles
Cynthia MontgomeryCynthia Montgomery
Group Underwriter II at Elevance Health dba Anthem Blue Cross Blue ShieldGroup Underwriter II at Elevance Health dba Anthem Blue Cross Blue Shield
Caryn A. GranitoCaryn A. Granito
Grievance & Appeals Lead (Remote) at Elevance Health (Anthem Blue Cross Blue Shield)Grievance & Appeals Lead (Remote) at Elevance Health (Anthem Blue Cross Blue Shield)
Jasmine CastonJasmine Caston
Broker Service Concierge Representative at Elevance Health (Anthem Blue Cross Blue Shield)Broker Service Concierge Representative at Elevance Health (Anthem Blue Cross Blue Shield)