Kandyce Phelps
Texicare
Belton,Tx
15
years of professional experience
Dynamic Case Manager with extensive experience at Ascension, excelling in insurance verification and regulatory compliance. Proven track record in enhancing patient education and referral coordination, ensuring timely resolutions of complex claims. Adept at fostering communication among healthcare teams, driving efficiency, and maintaining high standards of customer service.
Diligent Prior Authorization Specialist with proven track record in navigating complex healthcare systems and ensuring timely approval of medical treatments. Successfully facilitated seamless communication between providers and insurance companies to streamline authorization processes. Demonstrated expertise in medical coding and patient advocacy.
Work History
Senior Member Services Representative
4 Months- Resolved complex member inquiries regarding eligibility, benefits, claims, and plan coverage with accurate guidance.
- Assisted members with enrollment, referrals, prior authorizations, and provider directory navigation using service systems.
- Documented call details, correspondence, and case updates in CRM systems to maintain accurate member records.
- Escalated sensitive complaints and service issues to appropriate departments while tracking resolution through completion.
- Interpreted health plan materials and policy details to explain coverage options in clear, member-focused language.
- Trained new representatives on call handling, documentation standards, and service workflows to support team consistency.
- Coordinated with claims, billing, and provider teams to research discrepancies and deliver timely follow-up.
- Improved member service processes by identifying recurring issues and recommending workflow adjustments to reduce repeat contacts.
- Conducted regular audits of member accounts to ensure compliance with company policies and procedures.
- Provided support during high call volume periods by efficiently managing multiple inquiries simultaneously while maintaining professionalism.
- Contributed to the development of department goals and objectives, aligning them with company mission and vision.
- Took part in initiatives aimed at improving overall company performance by providing input on current workflows or suggesting possible improvements.
- Analyzed trends in member inquiries to identify areas for improvement or potential product enhancements based on feedback received from clients.
- Participated in cross-functional teams to address ongoing challenges within the organization, leading to process improvements.
- Supported the introduction of new products or system changes by adapting quickly and assisting colleagues as needed with the transition period.
- Streamlined processes for member account maintenance, resulting in improved efficiency and accuracy.
- Maintained confidentiality of sensitive member information at all times, adhering strictly to data protection regulations.
- Applied skills and knowledge of application such as: Snowflake, tableau, Salesforce, work force management, slack, Microsoft applications and more.
Prior Authorization Specialist
2 Months- Processed prior authorization requests efficiently, ensuring timely approvals for patient treatments.
- Collaborated with healthcare providers to gather necessary documentation and resolve authorization issues.
- Reviewed and analyzed medical records to determine eligibility for services based on insurance guidelines.
- Implemented process improvements that enhanced the accuracy of authorization submissions and reduced turnaround times.
- Maintained thorough knowledge of insurance plan requirements, facilitating accurate and timely completion of authorization forms.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Verified eligibility and compliance with authorization requirements for service providers.
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Reduced turnaround time for prior authorization requests by utilizing electronic submission methods.
- Monitored pending cases closely, proactively following up on outstanding documentation needed for successful approval outcomes.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Tracked referral submission during facilitation of prior authorization issuance.
- Researched denied claims and contacted insurance companies to resolve these issues.
- Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
- Managed approximately 30-45 Prior Authorizations daily
Case Manager
1 Year 10 Months- Analyzed health benefits plans for compliance with regulations and company policies.
- Reviewed claims for accuracy and addressed discrepancies with insurance providers.
- Educated employees on available health benefits options and enrollment procedures.
- Reviewed and processed health benefit claims to ensure accuracy of information.
- Resolved customer complaints regarding coverage or billing discrepancies, enhancing patient satisfaction.
- Coordinated with vendors regarding open enrollment issues and plan changes.
- Researched medical claims inquiries from providers, employers, and members for resolution.
- Evaluated financial statements to ensure compliance with applicable state and federal regulations.
- Conducted research on various health insurance plans to determine eligibility requirements.
- Collaborated with management to update existing health benefit programs.
- Coordinated referral processes for patients to specialized healthcare providers.
- Managed patient records using electronic health record systems.
- Collaborated with medical staff to ensure accurate patient information transfer.
- Assisted patients in understanding referral procedures and requirements.
- Streamlined communication between healthcare teams and patients, improving care coordination.
- Maintained confidentiality of patient information in compliance with regulations.
- Evaluated referral requests for appropriateness based on clinical guidelines.
- Educated patients about available services and resources within the healthcare system.
- Communicated regularly with referring physicians, nurses, case managers, social workers, and other healthcare professionals regarding referral processes and requirements.
- Entered confidential patient information and updated electronic records in database.
- Assisted patients in understanding their insurance coverage and answered questions about referrals, authorizations, and other related issues.
- Coordinated with provider offices to ensure timely completion of referrals prior to scheduled appointments.
- Tracked referral request progress and resolved issues to maintain smooth processing.
- Managed and obtained insurance authorizations for patient referrals from physicians.
- Liaised with healthcare facility personnel, insurance representatives, physicians and vendors for smooth communication.
- Reviewed all documentation associated with each referral request to ensure compliance with relevant regulations.
- Resolved escalated patient complaints relating to denied or delayed referrals promptly.
- Developed strategies that enhanced departmental efficiency and maintained high customer service standards.
- Educated patients on how their health plan works so they can make informed decisions about their care options.
- Identified potential problems with referrals before submitting them to insurers and worked with providers to resolve those issues quickly.
- Contacted patients to confirm or reschedule appointments to minimize no-show appointments.
- Provided support to referring physicians in obtaining pre-authorization for services as necessary.
- Processed incoming referral requests for medical services and submitted them to the appropriate insurance companies for authorization.
- Monitored changes in payer policies related to referral processing and communicated those changes internally.
- Collected required signatures to initiate referral process.
- Obtained PA for services such as diagnostic imaging.
Insurance & Referrals Benefits Specialist
1 Year 1 Month- Ensures all insurance, demographic, and eligibility information is obtained
- Obtains and verifies insurance authorizations/precertification
- Coordinated referrals and authorizations for patient services to ensure timely access to care
- Facilitated referrals to specialists for comprehensive care management.
- Assisted with referrals to specialists and monitored outcomes of referrals.
- Initiated referrals between primary care providers and specialists.
- Initiated referrals for specialty services when appropriate.
- Prioritized urgent referrals and follow-up care.
- Contacting customers and other parties (claimants, third parties such as medical providers, etc.)
- To assist in dealing with customer complaints in an effective and courteous manner, providing or seeking solutions as quickly as possible
- Manage claim submissions and provide oversight and guidance
- Knowledge of Government and Commercial policies and procedures
- Knowledge of ICD-9, CPT and HCPCS Coding
- Experience in PBM systems Navitus Health Solutions (Medicaid) Optum RX (Medicare)
- Microsoft Office (Outlook, Excel, Word)
- May coordinate requests for services between the multidisciplinary treatment teams and confirms insurance for each discipline
- Evaluated benefits plans and recommended improvements to enhance offerings.
- Provided guidance to employees on benefits eligibility and options available.
- Maintained communication with healthcare providers regarding referrals and authorizations.
- Maintained complete and accurate records of applications, forms and referrals.
- Coordinated referrals to outside agencies or specialists.
- Educated clients on available resources and referrals, enhancing their understanding of support options.
Insurance & Benefits Specialist
1 Year 2 Months- Reported visits and referrals via InSync daily, ensuring adherence to established timelines
- Liaised with outside referring physicians and facilities to resolve scheduling issues, reviewed and confirmed patient appointments
- Administered employee benefits programs and ensured compliance with regulations.
- Coordinated with insurance carriers to resolve claims and coverage issues.
- Educated employees on benefit options and enrollment processes.
Insurance & Benefits Specialist
2 Years 5 Months- Obtained and verified insurance authorizations and precertification to facilitate patient access to care
- Experience in PBM systems Navitus Health Solutions (Medicaid) Optum RX (Medicare)
- Oversaw management of physician requests for patient care services.
- May coordinate requests for services between the multidisciplinary treatment teams and confirms insurance for each discipline
- Referral Coordinator - Authorizations Specialist
- Assists in checking out patients and assists them with referral processing and scheduling process
- Complete pre-registration/registration within established error thresholds
- Enters, reviews and submits charges for patient procedures and services daily.
- Collected co-payments and reconciled daily reports and deposits to ensure financial accuracy
- Provides assistance to other Health System or physician offices staff regarding registration information and procedures
- Verifies and enters demographic information
- Improved quality of care with diligent attention to patient needs and delivery strategies.
- Conveyed medical and administrative policies and procedures to patients to enhance understanding and compliance
- Reduced risk and legal liabilities, consistently researching options and implementing recommendations.
- Updated office files daily and kept records organized.
Pharmacy Tech
1 Year 1 Month- Assisted pharmacist in filling prescriptions by efficiently pulling stock, pouring, counting, restocking, packaging, labeling, and pricing medications
- Received and processed telephone orders from physicians and designees, ensuring accurate and timely medication prescription fulfillment
- Assist in checking and removing out-of-date product as instructed by the pharmacist
- Executed additional duties to enhance team operations and support overall pharmacy workflow
- Works with manager & pharmacists to perform other functions to care for patients
- Performs work processes efficiently at each work station
- Experience in PBM systems Navitus Health Solutions (Medicaid) Optum RX (Medicare)
Front Desk Receptionist
3 Years 2 Months- Greets patients and visitors into the clinic in a prompt, courteous and professional manner
- Registers all new patients into the system
- Collects co-pays, deductible and other out of pocket amounts at time of visit
- Notifies nursing staff of patient arrivals, placing charts in appointment order
- Organized and prepared new patient charts for efficient onboarding and record-keeping
- Perform clerical duties such as data entry
- Addressed customer complaints courteously, providing timely solutions to enhance patient satisfaction
- Proficiency in planning written and verbal communications
Correctional Officer
3 Years 5 Months- Assist in supervising the movement of prisoners to/from work assignments, meals, recreation and housing units/dormitories
- Assist in the prevention of escapes
- Created and maintained atmosphere conducive to rehabilitation of prisoners
- Interviewed and counseled inmates on complaints or problems to facilitate changes in attitude and behavior
- Conducted weekly inspections of institution to ensure cleanliness, security, and safety standards were met for all inmates
- Oversees and coordinates the security operations of the Unit
- Executed correctional duties for various shifts
Education
Certificate - Medical Billing & Coding
Skills
Claim processing
Insurance verification
Referral coordination
Patient education
Physician authorizations
Medical coding
Medical terminology
Patient scheduling
Microsoft Office
Communication skills
Physician communication
Medical appeals handling
Patient referrals
Data entry
Electronic health records proficiency
Benefit coverage
Insurance procedures
Pharmacy benefit management
Claims processing experience
Utilization review experience
Prescription coordination
Proficiency in Epic
ECW
Athena
Next Gen
CMM
Prompt PA
HIPAA compliance
ICD-10 coding
CPT coding
Medical billing procedures
Prior authorization process
Team lead
Supervisory experience
Education
true,other
Timeline
Senior Member Services Representative
Texicare
06.2026 - 10.2026Read More
Prior Authorization Specialist
Nyx Health
03.2026 - 05.2026Read More
Case Manager
Ascension
04.2024 - 02.2026Read More
Insurance & Referrals Benefits Specialist
Baylor Scott & White Health
03.2023 - 04.2024Read More
Insurance & Benefits Specialist
Aetna
09.2021 - 11.2022Read More
Insurance & Benefits Specialist
WellMed
03.2019 - 08.2021Read More
Pharmacy Tech
Walgreens Pharmacy
11.2018 - 12.2019Read More
Front Desk Receptionist
NextCare
03.2015 - 05.2018Read More
Correctional Officer
Bartlett State Jail
02.2012 - 07.2015Read More
ED2Go Vocare
Certificate from Medical Billing & Coding
Read More