DON CARLOS CORLEY
Rural Hall,NC
Summary
Behavioral Healthcare Management Professional, specializing in Utilization Management and Senior Market Administration (SMA); Companies include Blue Cross Blue Shield of NC and Elevance Health Sales/Customer Service Professional with a successful track record with such companies as: The Pepsi Bottling Group, Time Warner Cable, American Express, and GMAC Insurance. Promoted frequently at PBG to take on more complex assignments; five roles in ten years. Very adaptable and flexible.
Lead Representative with strong background in driving operational efficiency and delivering impactful results. Skilled in team collaboration, problem-solving, and managing dynamic environments. Reliable with focus on adaptability, customer service, and effective communication. Equipped with leadership, strategic planning, and conflict resolution abilities that align with organizational goals.
Overview
14
14
years of professional experience
Work History
Utilization Management Lead Rep
Elevance Health
08.2019 - Current
- Responsible for managing a team of up to 15 Utilization Management Representatives in a Call Center environment, After Hours (5pm- 8am). Duties included but not limited to-
- Responsible for conducting utilization management reviews for mental health and substance use disorder inpatient and outpatient benefits through telephonic and written processes. Also provides telephonic support for crisis intervention, assessment and short-term problem resolution and referral to appropriate provider(s).
- Uses appropriate screening criteria knowledge and clinical judgment to assess member needs to ensure access to medically necessary quality behavioral healthcare in a cost-effective setting in accordance with UM Clinical Guidelines and contract.
- Refers cases to Peer Reviewers as appropriate.
- Performs psychiatric and substance abuse or substance abuse disorder assessment coordination implementation case planning monitoring and evaluating to promote quality member outcomes to optimize member health benefits and to promote effective use of health benefits and community resources.
- Provided Best Practices for both Call/Fax, maintained Audit records monthly
- Served as Subject Matter Expert, providing guidance and expertise to both Utilization Management Reps and Clinicians
Senior Market Administration Customer Service Professional
Blue Cross Blue Shield NC
07.2011 - 08.2019
- Specifically responsible for Medicare Advantage Plans, Blue Card (IPP), and Medicare Supplement.
- Managed Lobby/Walk-ins for current and prospective members. Identify challenges and provide solutions. Process payments, provide accurate information regarding claims, billing, enrollment. Assisted over 4,800 walk-ins in 2014.
- Advise prospective members during AEP (Annual Enrollment Period), resulting in incremental growth. Consult with members on several lines of business- HMO, PPO, Med Supp and Commercial
- Establish and build rapport with members. Consistently meet/exceed target goals
- 2017 Customer Service and Support Advisory Board Member
- Assisted members/providers by answering questions and responding to inquiries.
- Developed rapport with members/providers through active listening and empathetic communication, resulting in enhanced satisfaction levels.
Education
Associate of Applied Science - Computer Science, Supply Chain Management
Forsyth Technical Community College
Winston-Salem, NC05.2011
Bachelor of Arts - Major Business Administration, Minor Economics
University North Carolina At Greensboro
Greensboro, NC01.1983
Skills
- Strong oral, written, and interpersonal communication abilities, along with excellent problem-solving, facilitation, independent decision-making, and analytical skills
- Proficient in MS Office and have a strong technical aptitude
- Effective team leadership
- Task delegation
- Strong leadership
- Developing client partnerships
Timeline
Utilization Management Lead Rep
Elevance Health
08.2019 - Current
Senior Market Administration Customer Service Professional
Blue Cross Blue Shield NC
07.2011 - 08.2019
Associate of Applied Science - Computer Science, Supply Chain Management
Forsyth Technical Community College
Bachelor of Arts - Major Business Administration, Minor Economics
University North Carolina At Greensboro
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