Esmiralda Smith

Clinical-Intake Coordinator/Inbound-Outbound Queue Associate/Patient Advocate

CVS/Aetna

Plantation FL-Albany OH

06.2008 - Current

Supports comprehensive coordination of medical services such as intake, screening and referrals to Aetna Medical Services Programs
Approve services that do not require a medical review in accordance with the benefit plan
Perform non-medical research including eligibility verification, COB, and benefits verification
Maintaining accurate and complete documentation of required information that meet risk management, regulatory, and accreditation requirements
Promote communication, both internally and externally to enhance effectiveness of medical management services such as claim administrators, Plan Sponsors, and third-party payers as well as members, family and health care team members
Protect the confidentiality of member information and adheres to company policies regarding confidentiality
Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards where applicable, while adhering to company policy and procedures
Outbound calls to providers under the direction of Medical Management Nurses to obtain clinical information for approval of medical authorizations
Uses Aetna Systems such as ONXT, ProFAX, PROPAT, and Milliman Criteria
Screening of requests for appropriate referral to medical services staff
Management of Initial Evaluations for Utilization and Case Management departments
Management of Admissions/ Verification of Insurance
Manage Patient Charts/Clerical duties/ Inbound/Outbound and Referrals Queue
Proficient in computer work and familiar with Office and Excel

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