Janeece De Luna
Austin,Texas
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
13
13
years of professional experience
Work History
Program Coordinator
Superior Health Plan
11.2016 - Current
- Initiate authorization requests for output or input services in keeping with the prior authorization list
- Research claims inquiry specific to the department and responsibility
- Perform tasks necessary to promote member compliance such as verifying appointments, obtaining lab results
- Assess and monitor inpatient census
- Screen for eligibility and benefits
- Identify members without a PCP and refer to Member Services
- Screen members by priority for case management assessment
- Perform transition of care duties to include but not limited to, contact the member’s attending physician, member or medical power of attorney, other medical providers (home health agencies, equipment vendors) for information pertaining to special needs
- Coordinate services with community based organizations
- Attend marketing and outreach meetings as directed to represent the plan
- Produces and mails routine CM letters and program educational material
- Data enter assessments and authorizations into the system.
Authorization specialist
Superior Health Plan
07.2013 - 11.2016
- Supports authorization requests for services in accordance with the insurance prior authorization list
- Supports and performs data entry to maintain and update authorization requests into utilization management system
- Assists utilization management team with ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines
- Contributes to the authorization review process by documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination
- Remains up-to-date on healthcare, authorization processes, policies and procedures.
Enrollment Broker
Maximus Inc
05.2011 - 07.2013
- Assisted clients with health Insurance applications and Eligibility requirements
- Assisted clients with enrollment into a managed care health or dental plan and selecting a Primary care physician and main dentist
- Accurately performed all data entry functions to reflect customer activity
- Gave appropriate referrals to other agencies when needed.
Education
Associate of Arts in Social Work -
Austin Community College
12.2024
Skills
- Detail Oriented
- Excellent written and oral communication
- Develops positive workplace relationships
- Problem solving
- Adaptability
Languages
English
Spanish
Timeline
Program Coordinator
Superior Health Plan
11.2016 - Current
Authorization specialist
Superior Health Plan
07.2013 - 11.2016
Enrollment Broker
Maximus Inc
05.2011 - 07.2013
Associate of Arts in Social Work -
Austin Community College