Keisa Cloudy

• Serves as a resource to the Claims Department in determining medical necessity of claim submitted by network physicians according to Health Solutions payor’s prospective review criteria and authorization procedures.

• Coordinates pre-certification activities with contracted health plans and interfaces with providers and/or enrollees when pre-certification issues arise.

• Educates and affords training to network physicians/office staff on prospective review/precertification requirements.

• Collects and/or documents all required enrollee clinical and co-morbidity information during the pre-authorization process to support care management initiatives and sound decision making for review determinations.

• Process incoming referrals to providers within a reasonable turnaround time according to Medicare guidelines, including but not limited to Home Health, DME, inpatient and outpatient surgical procedures, genetic testing, medical pharmacy, dental, vision, and out of network requests.
• Determine patient coverage, as well as carry out denial of service authorizations.
• Collect and process clinical information from Physicians and Providers, and make reasonable clinical decisions.
• Provide exceptional customer service.
• Interface with Providers and Customers and identify existing barriers.
• Refer customers to needed services, including but not limited to social services, transportation, food services, behavioral health, etc.
• Provide education to customers/families with chronic health conditions.