Darlene Ferguson
Las Vegas,Nevada
Summary
Dynamic Utilization Management Intake Coordinator at Devoted Health with expertise in prior authorization processing and clinical documentation review. Proven ability to enhance operational efficiency and ensure compliance with HIPAA regulations. Adept at member outreach and problem-solving, delivering exceptional service while managing complex health information exchanges.
Overview
6
6
years of professional experience
Work History
Utilization Management Intake Coordinator
Devoted Health
02.2023 - Current
- Company Overview: UM Intake Coordinator at Devoted you will support the medical management operations of the health plans for Medicare.
- Triaging/entering incoming prior authorization request using CPT and ICD 10 codes
- Processing HIE (Health Information Exchange) discharges and admissions to multiple facilities
- Reaching out to hospitals and provider offices to obtain important clinical documentation
- Contacting hospitals and provider groups to ensure communication of clinical decision
- Managing clinical contact list for hospitals and provider groups
- Providing operational support for key medical management processes enabling nurses and physicians to make efficient, high quality decisions
- Reviewing clinical documentation to attach medical records to authorization.
- Contact members regarding approval and denials of benefits and provide their appeal rights.
- Scheduling peer to peer with director and providers
- UM Intake Coordinator at Devoted you will support the medical management operations of the health plans for Medicare.
Unemployment Insurance Rep 2
Department of Employment Training and Rehabilitation
04.2020 - 02.2023
- Receiving and processing new and reopened unemployment claims via telephone
- Identifying and resolving issues
- Fact finding and writing decisions concerning entitlement to benefits and tax ruling for base period employers
- Investigating claims paid for quality control
- Fraud detection and overpayment recovery
- Processing and responding to questions from employers, the general public and other agencies seeking information regarding unemployment insurance benefits
- Performing related duties as assigned
Customer Service Representative
Anthem BlueCross BlueShield (Mindlance Temp Agency)
09.2019 - 04.2020
- Provide customer service to seniors on Medicare Supplement plan advising of benefit coverage while following HIPAA guidelines.
- Analyze claims/ EOB’S and provide information/solutions.
- Collecting and verifying a patient's insurance information
- Payer Appeals and Disputes.
- Process payments on policies payer
- Contact provider offices on behalf of members regarding health coverage.
- Advise members about their deductible, coinsurance and copayment.
- Update member demographics as requested.
- Canceled policies requested by members.
- Thoroughly documents inquiry outcomes for accurate tracking and analysis.
- Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
- Researches and analyzes data to address operational challenges and customer service issues.
- Provides external and internal customers with requested information.
- Under immediate supervision, receives and places follow-up telephone calls / emails to answer customer questions that are routine in nature, knowledge of company services, products, insurance benefits, provider contracts and claims.
- Seeks, understands and responds to the needs and expectations of internal and external customers.
Education
Bachelor of Science - Healthcare Administration
California State University
12.2016
Associates of Arts - Interdisciplinary Studies
Los Angeles Southwest College
06.2014
Skills
- Customer service
- Prior authorization processing
- Clinical documentation review
- Health information exchange
- Multi-line phone operations
- Member outreach
- Problem solving
- Multi-line phone operations
- Insurance verification
- Microsoft Office
- Microsoft Word
- Microsoft Excel
- PowerPoint
- Outlook
- Epic
- Claims processing
- Medical terminology
- HIPAA
- CPT coding
- ICD 10 coding
- Data entry
- general ledger
- Problem solving
- Spreadsheet
- Database accounting
- Finance
- Risk management
- Quality assurance
- Multitasking
- 10 key by touch
- Type 50 wpm
Timeline
Utilization Management Intake Coordinator
Devoted Health
02.2023 - Current
Unemployment Insurance Rep 2
Department of Employment Training and Rehabilitation
04.2020 - 02.2023
Customer Service Representative
Anthem BlueCross BlueShield (Mindlance Temp Agency)
09.2019 - 04.2020
Bachelor of Science - Healthcare Administration
California State University
Associates of Arts - Interdisciplinary Studies
Los Angeles Southwest College
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