Crystal Darden
Angier,NC
Summary
Experienced professional with a background in eligibility verification and case management within health plan environments. Demonstrated ability to analyze and process complex eligibility requests, ensuring compliance with established policies and guidelines. Collaborated effectively with cross-functional teams to resolve enrollment issues and improve operational efficiency. Proven track record of conducting thorough reviews of documentation to uphold policy compliance and enhance member access to services.
Overview
4
4
years of professional experience
Work History
Eligibility Specialist
Centene
Angier, NC
04.2025 - 09.2026
- Verified Medicaid and marketplace eligibility using enrollment systems and plan documents.
- Applied Centene policy guidelines when evaluating eligibility requests and documentation.
- Reviewed member eligibility records for Centene health plan enrollments and coverage updates.
- Processed eligibility changes for member accounts, referrals, and coverage corrections.
- Responded to member and provider questions about benefits, enrollment, and eligibility status.
- Coordinated with internal teams to resolve enrollment issues and member access concerns.
- Processed client applications in accordance with established guidelines.
- Researched discrepant coverage data across claims, enrollment, and eligibility sources.
- Explained reasons behind application denials and recommended further action.
Authorization Specialist
Centene
Angier, NC
03.2023 - 04.2025
- Reviewed prior authorization requests for Centene health plan members
- Reviewed utilization requests for health plan members and provider submissions.
- Verified eligibility and coverage guidelines for service approvals
- Verified medical necessity using plan guidelines and clinical criteria.
- Tracked authorization cases through internal workflow systems
- Updated authorization records in case management and tracking systems.
- Entered data into electronic medical record system accurately and efficiently.
- Analyzed denials received from third party payers to identify trends in denials and develop proactive measures for resolution.
- Assisted in the development of new processes and protocols to improve operational efficiency.
- Gathered clinical documentation for concurrent and retrospective review.
- Performed concurrent reviews when requested by providers or authorized representatives.
- Analyzed medical records to assess the level of care, utilization trends, and resource utilization.
- Interpreted requirements and translated them into clear operational direction.
- Collaborated with cross-functional teams to align tasks with business needs.
- Conducted training sessions for new staff to familiarize them with operational protocols. sessions for new employees regarding company policies related to the authorization process.
- Ensured that all authorizations are documented accurately in the patient's medical record.
- Collaborated with internal departments such as Case Management, Quality Improvement, Pharmacy Services. to obtain necessary information for case reviews.
Referral Specialist
Centene
Angier, NC
04.2022 - 03.2023
- Managed and obtained insurance authorizations for patient referrals from physicians.
- Coordinated prior authorization details with providers, specialists, and care management teams.
- Reviewed referral requests in Centene health plan systems for medical necessity and completeness.
- Tracked referral status updates across utilization management workflows and member records.
- Communicated referral requirements to providers using Centene service standards and plan guidelines.
- Resolved referral discrepancies by verifying eligibility, benefits, and authorization information.
- Documented referral activities in electronic case management systems and shared notes.
Education
Harnett Central High School
Lillington, NCSome College (No Degree) - Business Administration
Wake Technical Community College
Raleigh, NCSkills
- Eligibility verification
- Medicaid enrollment
- Authorization review
- Referral processing
- Claims reconciliation
- Medical policy review
- Case management
- EMR documentation
- Attention to detail
- Problem solving
- Clear communication
- Cross functional collaboration
- Policy compliance
- Eligibility procedures
- Documentation and reporting
- Microsoft office
- Knowledgeable in [software]
- Effective communication skills
- Telephone etiquette
- Documentation and paperwork
- Appointment scheduling
- Confidentiality
- Resource information
- Income verification
- Benefits administration
- Programming
- Medicaid
- Public assistance programs
- Data entry
- Task prioritization
- Computer proficiency
- Team building
- Government Programs Understanding
- Referral coordination
Timeline
Eligibility Specialist
Centene
04.2025 - 09.2026
Authorization Specialist
Centene
03.2023 - 04.2025
Referral Specialist
Centene
04.2022 - 03.2023
Harnett Central High School
Some College (No Degree) - Business Administration
Wake Technical Community College