LAKENDRIA SIMS
Montgomery
Summary
Detail-oriented and compassionate Utilization Review Specialist with over 8 years of healthcare experience, specializing in Medicare and Medicaid. Proven track record of delivering exceptional remote customer service, streamlining authorization processes, and ensuring regulatory compliance. Skilled in critical thinking, effective communication, and maintaining high levels of patient satisfaction in remote environments.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Remote Utilization Management Representative
Molina Healthcare
02.2023 - Current
- Facilitated remote coordination of patient services, improving response times and patient satisfaction.
- Verified insurance eligibility and benefits, ensuring accuracy in claims and authorizations.
- Collaborated with providers to efficiently collect prior authorization documentation.
- Trained new team members in HIPAA-compliant remote procedures and systems.
- Conducted preservice and admission reviews, concurrent reviews, and transitional care planning.
- Implemented discharge planning and ensured continuity of member care post-hospital discharge.
- Managed after-hours availability and retrospective reviews, providing medical case management for specific conditions.
- Developed clinical policies and criteria, processed provider appeals, and analyzed utilization data for compliance.
Remote Call Center Representative
TRC Staffing Services Inc.
Montgomery
09.2010 - 01.2023
- Evaluated customer information to resolve issues, develop solutions, and maintain high service quality.
- Engaged with customers regarding concerns with products and services to drive sales and resolve problems.
- Enhanced productivity by adhering to call scripts while maintaining control over conversation direction.
- Consistently exceeded revenue quotas through effective product and service promotion during calls.
- Preserved revenue streams by employing strong communication and negotiation skills, offering refunds as a last resort to ensure customer satisfaction.
Remote Call Center Agent
Bank of America
Montgomery
08.2010 - 11.2022
- Enhanced productivity and customer experience by adhering to call scripts and maintaining quality standards.
- Educated customers on using company systems, completing forms, and obtaining desired services.
- Contributed to achieving and maintaining industry-leading customer service ratings.
- Analyzed and escalated complaints, issues, and grievances for timely investigation and response.
- Monitored user account data, ensuring security protocols were upheld to prevent asset theft.
Education
Certified Nursing Assistant (CNA) -
Nursing Academy of Montgomery
Montgomery, AL05.2006
High School Diploma -
Selma High School
Selma, AL05.2005
Associate of Business Administration - Management
Faulkner University
Montgomery, ALPhlebotomy Certification -
Selma University
Selma, ALSkills
- Remote Customer Service
- Medicare & Medicaid Knowledge
- Utilization Management
- HIPAA Compliance
- Prior Authorizations & Insurance Verification
- Medical Documentation & Records Management
- Microsoft Office & Excel
- Clinical Assessment & Discharge Planning
- Call Center & Telehealth Communication
- EMR/EHR Systems
Certification
- CNA – Certified Nursing Assistant
- NHA – Clinical Medical Assistant
References
Available Upon Request
Timeline
Remote Utilization Management Representative
Molina Healthcare
02.2023 - Current
Remote Call Center Representative
TRC Staffing Services Inc.
09.2010 - 01.2023
Remote Call Center Agent
Bank of America
08.2010 - 11.2022
Certified Nursing Assistant (CNA) -
Nursing Academy of Montgomery
High School Diploma -
Selma High School
Associate of Business Administration - Management
Faulkner University
Phlebotomy Certification -
Selma University