Summary
Overview
Work History
Education
Skills
Timeline
Generic

Gilda Robert-Hunter

Jonesboro,GA

Summary

I am seeking an entry-level position with the opportunity for advancement that will allow me to use the full range of my qualifications. I have dedicated over 10 years in Operations, Managed Healthcare and Medical Management. I am proven to deliver exemplary level of healthcare service delivery to members and providers. Plan and implement strategies for developing improved health care management. Proven problem solver and excellent communicator. Strong organizational skills, superb understanding of data collection and performance metrics. Recognized for staff development leading to high performing teams.

Overview

12
12
years of professional experience

Work History

Post Service Review Specialist (Medical Management)

Emblem Health
2 2022 - Current
  • Conducted root cause analysis on recurring issues encountered during reviews; proposed viable solutions that led to long-term improvements.
  • Assists with special investigations and processing of pended high dollar claims.
  • Educated members and providers regarding determinations while offering appeal and peer to peer options.
  • Performed prior authorization review of services requiring notification.
  • Evaluated trends in authorization denials to identify areas for improvement in both internal processes and external communications with payers.
  • If authorization is required for a denied claim; I am responsible for creating an retrospective authorization and send RFI (Request for Information) to the requesting facility or provider.
  • Submit medical records for for cases that require review for medical necessity.
  • Enhanced patient care by efficiently coordinating utilization management processes and reviewing medical records for case appropriateness.
  • Maintained accurate documentation of all reviews, appeals, and decisions in line with organizational standards and requirements.
  • Ensured regulatory compliance by staying updated on industry guidelines and applying them to daily tasks and assessments.
  • Communicate authorization decisions and important benefit information to providers and members via mail in accordance with applicable federal and state regulations
  • Increased overall efficiency by streamlining authorization processes for medical procedures which includes, adjusting approved authorizations, updating of carve out days and adding additional days to authorizations for review per provider request.
  • Manual notification of Medicaid and Commercial untimely submission denials.
  • Support clinical staff by providing timely updates on the status of prior authorizations for various services.
  • Identified areas of improvement in operational workflows, leading to increased productivity and reduced errors.
  • Maintain an understanding of utilization management/claims/grievance and appeals program.
  • Served as a subject matter expert on various projects, providing valuable input towards achieving project objectives in a timely manner.
  • Managed a high volume of reviews within tight deadlines, ensuring timely completion and client satisfaction.
  • Processed and certified documents for accuracy and compliance with government regulations.
  • Ensured prompt resolution of denied claims through comprehensive analysis of denial reasons and timely submission of necessary documentation for reconsideration or appeal.
  • Provided support during peak periods by assisting other departments with workload overflow; demonstrating adaptability.
  • Developed appeals functions, policies and procedures and documentation.
  • Organized and managed appeals, claims and authorization caseloads, prioritizing high-priority cases for timely resolution.

Claims Examiner

Health First
09.2021 - 02.2022
  • Review, process and adjudicate medical and facility claim in using Macess and MHS for Medicare, Medicaid and commercial lines of businesses including contractual provisions, authorizations and Healthfirst Policy and Procedure.
  • Researched claims and incident information to deliver solutions and resolve problems.
  • Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
  • Identify defects and improving departmental performance by supporting quality, operational efficiency, and production goals
  • Reporting and presenting preliminary findings based on trending and interpretation
  • Verified patient insurance coverage and benefits for medical claims.
  • Assist with developing and participating in effective training and documentation
  • Continuously sought opportunities for process improvement, contributing innovative ideas to enhance overall departmental efficiency and effectiveness.
  • Soliciting and coordinating required information between Management staff and team members to complete daily assignments
  • Working on multiple audits, appeals or other ad hoc projects
  • Enhanced claim processing efficiency by conducting thorough investigations and maintaining accurate documentation.
  • Evaluated medical claims for accuracy and completeness and researched missing data.
  • Paid or denied medical claims based upon established claims processing criteria.

Medical Management Assistant

TriWest Healthcare Alliance
01.2020 - 09.2021
  • Process, adjudicate and review medical claims in Facets for the Department of Veteran Affairs
  • Enhanced claim processing efficiency by conducting thorough investigations and maintaining accurate documentation.
  • Maintained compliance with industry regulations and company policies while evaluating medical claims for accuracy and legitimacy.
  • Supported team members during periods of high workload, providing guidance on challenging cases or offering assistance when needed.
  • Streamlined workflow for faster resolution of medical claims through effective prioritization and organization.
  • Managed a high volume of complex cases, ensuring timely resolutions while maintaining attention to detail.
  • Reduced claim denial rates by thoroughly reviewing and validating medical documentation before submission.
  • Maintained thorough knowledge of medical terminology and coding systems, contributing to precise evaluations of claim submissions.
  • Followed up on denied claims to verify timely patient payment and resolution.

Care Authorization Specialist

TriWest Healthcare Alliance
03.2019 - 01.2020
  • Performed triage on all incoming medical authorization requests for the Department of Veteran Affairs.
  • Collaborated with healthcare providers to obtain necessary documentation for prior authorization requests.
  • Maintained compliance with HIPAA regulations, safeguarding sensitive patient information during the authorization process.
  • Supported clinical staff by providing timely updates on the status of prior authorizations for various services.
  • Evaluated trends in authorization denials to identify areas for improvement in both internal processes and external communications with payers.
  • Reduced processing times by effectively managing a high volume of authorizations, referrals, and appeals.

Acute Utilization Management Coordinator

Humana Inc.
09.2016 - 03.2019
  • Collaborated with medical review staff to report incoming clinical documentation that requires review for medical necessity.
  • Ensured regulatory compliance by staying updated on industry guidelines and applying them to daily tasks and assessments.
  • Enhanced patient care by efficiently coordinating utilization management processes and reviewing medical records for case appropriateness.
  • Actively participated in interdisciplinary team meetings to provide input on patient care, discharge planning, and resource utilization.
  • Served as a liaison between patients, families, caregivers, providers, payers, and community resources to ensure seamless transitions throughout the continuum of care.
  • Managed timely completion of assigned tasks, allowing for optimal orchard maintenance schedules.
  • Compiling information for reporting, organizing records, offering of Peer to Peer to providers as well as scheduling of Peer to Peer conferences
  • Submitted medical records for cases that had criteria failures and helped create and send letters for resolutions and approvals.
  • Documented inpatient stays, discharge instructions, and follow-up care.
  • Notification to members when provider’s contracts are altered.
  • Provided ongoing support to nursing staff through education on utilization management concepts as well as mentoring new team members.
  • Educated members and providers regarding determinations while offering appeal and peer to peer options.
  • Performed triage on all incoming medical records and appeal requests.

Customer Care Advocate- Long Term Care

United Health Group
04.2012 - 09.2016
  • Enhanced customer satisfaction by promptly addressing concerns and providing effective solutions.
  • Managed multiple priorities effectively while ensuring a high level of accuracy and attention to detail in all tasks performed.
  • Collaborated with team members to ensure consistent high-quality service delivery across the organization.
  • Documented customer concerns and inquiry resolutions such as member benefits, claims, pharmacy issues in internal computer system.
  • Contributed ideas for process improvements that led to reduced wait times for customers seeking assistance over the phone or via email/chat platforms.
  • Contacted outside providers on behalf of customers to help solve problems.
  • Handled difficult customer situations with grace and professionalism, consistently meeting first-call resolution metrics.
  • Served as a liaison between clients and internal departments to facilitate seamless coordination of efforts towards meeting client objectives.
  • Followed document protocols to safeguard confidentiality of patient records.

Education

Highschool diploma -

Miami Central Senior Highschool
Miami
05.2006

Skills

  • Industry Expertise
  • Task Delegation
  • Coaching and Mentoring
  • Teamwork and Collaboration
  • Microsoft Office
  • Problem-Solving
  • Complaint Handling
  • Multitasking Abilities
  • Analytical and Critical Thinking
  • Time management abilities
  • Adaptability

Timeline

Claims Examiner

Health First
09.2021 - 02.2022

Medical Management Assistant

TriWest Healthcare Alliance
01.2020 - 09.2021

Care Authorization Specialist

TriWest Healthcare Alliance
03.2019 - 01.2020

Acute Utilization Management Coordinator

Humana Inc.
09.2016 - 03.2019

Customer Care Advocate- Long Term Care

United Health Group
04.2012 - 09.2016

Post Service Review Specialist (Medical Management)

Emblem Health
2 2022 - Current

Highschool diploma -

Miami Central Senior Highschool

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Gilda Robert-Hunter