Kimberly Chambers

This position is responsible for ensuring accurate and timely clinical review of cases for medical necessity including assisting members on the telephone, reviewing medical records, reviewing cases which involves contract interpretation of health diagnoses, and utilizing knowledge of medical necessity criteria for all levels of health care from outpatient office visits to acute in-patient to out-patient office visits.

Currently Team Lead and I’m involved from every facet including daily communication with upper management. I also play a role Completion of all Daily Reports and Triaging of cases (Router).

• Provide accurate, valid and complete information by using the right methods/tools gathering information about clients
• Reading and implementing up to date processes

• Manage large amounts of incoming calls
• Working with Doctors and nurses daily to pre- cert patient medical procedures and assisting with issues that may arise from claims to benefits.
• Identify and assess customers’ needs to achieve satisfaction
• Build sustainable relationships of trust through open and interactive communication
• Provide accurate, valid and complete information by using the right methods/tools gathering information about clients
• Reading and implementing up to date processes
• Assessing, analyzing and interpreting complicated/escalated calls
• Undertaking risk analysis by developing statistical models
• Keeping knowledge of key issues up-to-date (market risk and compliance issues)

• Recruited, hired and trained all staff, providing direct supervision, ongoing staff development and continuing education to employees.
• Developed and updated policies and procedures, maintaining compliance with statutory, regulatory and local, state and federal guidelines relating to HIPAA, benefits administration and general liability.
• Communicated with patients, ensuring that medical information was kept private.
• Send necessary paperwork to employees, process claims, track benefit payments and time off due for all Leave of Absences including but not limited to: Disability, Workers’ Compensation, FMLA, , Paid Family and Medical Leave, Parental Leave, Military Leave, and Personal Leaves
• Review medical certification and determine eligibility, approving or denying leave requests and ADA reasonable accommodation requests in compliance with state and federal regulations