Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

Karema Nugent

Bay Shore,NY

Summary

Experienced Utilization Management Specialist with a demonstrated history of working within the health care industry. Highly dependable, ethical and reliable support specialist that blends advanced organizational and business acumen. Works effectively with cross-functional teams in ensuring operational and service excellence.

Overview

14
14
years of professional experience
1
1
Certification

Work History

SENIOR CARE SPECIALIST, UM INTAKE OPERATIONS

EMBLEM HEALTH
11.2020 - Current
  • Perform accurate and timely intake and data entry for all UM authorization requests and referrals for all lines of business, upon receipt of inbound utilization management requests, via call, fax, and web portal
  • Triage cases and assign receipts to appropriate teams
  • Respond to inquires from providers, facilities, and members
  • Conduct quality monitoring audits with supervisor to identity training and quality gaps that drive improvement
  • Assist and/or oversee training sessions to provide experience and support care to care specialist; assist with individual and team coaching
  • Create, interpret, review, edit, and organize departmental and company audits and reports
  • Review documents for accuracy, completeness, and timeliness for submission to the appropriate leadership teams.

RECEPTIONIST

HUNTINGTON HILLS REHABILITATION CENTER
06.2018 - 05.2024
  • Greeted and welcomed all new residents, families and visitors
  • Monitored premises, screened visitors, updated logs, created medical record cards and operated multi-line telephone systems.

SENIOR CLINICAL PRACTICE PLAN REPRESENTATIVE

NORTHWELL HEALTH
03.2016 - 06.2019
  • Assured timely verification of insurance benefits and obtained authorizations prior to patient appointments or procedures
  • Maintained strong knowledge of billing, coding and reimbursement related functions
  • Improved quality processes for increased efficiency and effectiveness as a member of the Revenue Cycle Policy and Procedure Process Improvement committee.

COORDINATOR, VERIFICATION INTAKE

NORTHWELL HEALTH
06.2012 - 03.2016
  • Verified all insurance coverage and obtained authorizations for Home Care patients
  • Served as a liaison between home care discharge planner, nursing, verification and reimbursement departments.

CUSTOMER SERVICE REPRESENTATIVE

NORTHWELL HEALTH
03.2010 - 06.2012
  • Communicated with patients to provide explanation of hospital bills, resolved inquires or disputes related to bill
  • Processed financial assistance applications by obtaining financial income particulars
  • Created payment arrangements for out of pocket balances.

Education

BACHELOR OF SCIENCE - Science, Technology and Society

FARMINGDALE STATE COLLEGE
05.2014

Skills

  • Problem Solving
  • MS Office
  • Process improvement
  • Salesforce
  • Claims investigation and research
  • Training and coaching
  • Quality Assurance
  • Strong verbal and written communication skills
  • Customer Service
  • Critical thinking

Certification

  • Google Data Analytics

Anticipated completion: August 2024

Timeline

SENIOR CARE SPECIALIST, UM INTAKE OPERATIONS

EMBLEM HEALTH
11.2020 - Current

RECEPTIONIST

HUNTINGTON HILLS REHABILITATION CENTER
06.2018 - 05.2024

SENIOR CLINICAL PRACTICE PLAN REPRESENTATIVE

NORTHWELL HEALTH
03.2016 - 06.2019

COORDINATOR, VERIFICATION INTAKE

NORTHWELL HEALTH
06.2012 - 03.2016

CUSTOMER SERVICE REPRESENTATIVE

NORTHWELL HEALTH
03.2010 - 06.2012

BACHELOR OF SCIENCE - Science, Technology and Society

FARMINGDALE STATE COLLEGE

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