Kristen DeLuca

Validates provider database entries to meet customer requirements for contracting, network management, and credentialing.

Maintains critical provider information on all claims and provider databases.

Synchronizes data among multiple claims systems and application of business rules as they apply to each database.

Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing

• Support team in database systems and tools to research provider data issues
• Identify, Analyze, Monitor and Research process improvement opportunities and communicate with various levels of management and business partners.
• Identify needed updates to documentation including creation of new SOPs and documents.
• Develop and maintain productive work relationships
• Use pertinent data and facts to identify and solve a range of problems within area of expertise
• Research and analyze provider data requests and problems, often in form of special projects and ad-hoc requests. Maintain knowledge of business processes in a changing environment to ensure the level of expertise required for the role by performing data loading to keep skills current.

• Process admission cases for UT market through phone, fax and internal submission.
• - Create reports for hospital admission census
• - Audit admit cases for accuracy
• - Create and analyze pended claims report for UT market
• - Gather and data enter clinical specifics to build authorization for clinicians.
• - Process administrative authorization requests submitted both electronically and paper within compliance timeframes, in various clinical platforms.
• - Serves as a liaison between call and clinical operation to investigate and resolve authorization conflicts that are submitted by claim processors.
• - Outbound calls to providers of service to withdrawal and/or update authorizations.
• - Outbound member notification calls within defined regulatory timeframes.
• - Outbound calling to providers of service to obtain consumers treatment status as a part of the access to care process.
• - Generate written approval notification letters using ELGS (Electronic Letter Generation System)
• - Manually fax authorization letters to provider for members at IP facilities to ensure regulated written notification timeframes are met.
• - Process various non-clinical admin tasks in support of clinical operations.
• - Navigate and document multiple clinical applications and SharePoint sites
• - Submit Electronic Provider Updates requests.

• - Interact with external service providers and the Option Care Commercial Team to transition new patients into service with Option Care
• - Coordinate the onboarding of referrals between different functional areas within Option Care including Pharmacy, Nursing, Warehouse and Revenue Cycle
• - Maintain and grow relationships with referral sources; serve as a primary point of contact and representative of Option Care
• - Communicate frequently with the commercial team to provide updates on patient referral status and resolve any related issues
• - Responsible for collecting, reviewing and completing applicable care transition documents
• - Accountable for setting new patients up on autopay, presenting copay assistance plans and foundation assistance plans

• - Collect and manage billing sheets from therapists in the Hands, Neurology and Pediatric departments
• - Use SMART and MS4 to enter billing information into two systems and ensure numbers align
• - Enter timesheets of therapists into SMART system.
• - Send appropriate new patient evaluation sheets to HIM for correct coding

• - Greet and register patients for appointments
• - Maintain composure and professionalism in high-stress situations
• - Maintain front desk responsibilities including upkeep of waiting room, checking inbound communications
• - Conducts all internal referrals promptly
• - Handle and reconcile AR/AP functions
• - Manage inbound communication for EPIC program including confidential physician messaging
• - Coordinate appointments aligning to physician requests

• - Answer phones and greet guests. Write and send out thank you cards, mail reports and document tracking numbers and shipping information
• - Maintain a color-coded status board keeping track of cases and documentation status for CEO
• - Receive and document all daily status information, field investigative sheets, chronological reports and film turned in by field investigators.
• - Update field investigative sheets with necessary information