Liala Suraleigh
Greensboro,NC
Summary
Versatile professional serves as the first point of contact for patients by verifying insurance, handling paperwork, and preparing records. Patient-oriented and helpful candidate familiar with MS Office and EHR systems coupled with thorough knowledge of medical terminology from a direct patient care perspective as well as a payer perspective. Committed to providing personalized service and quality patient care.
Overview
3
3
years of professional experience
Work History
Utilization Management Coordinator
Humana
06.2022 - 12.2022
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries
- Determined medical necessity and cost-effectiveness of services through utilization review processes
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria
- Adheres to governmental compliance guidelines for accurate claims processing
- Identifies Medical, HCPCS and CPT codes to place on record for Medical Director Review.
- Enhanced patient care by efficiently coordinating utilization management processes and reviewing medical records for case appropriateness.
Care Management Support Assistant
Humana
06.2021 - 06.2022
- Contributed to the administration of care management for Humana nurses and social workers
- Performed required Medicare Health Risk assessments (HRA) on D-SNP Members
- Managed high call volume, prioritizing cases and providing prompt assistance to members
- Utilized medical knowledge to accurately document patient conditions for Case Manager
- Evaluated members needs and social determinants of health
- Demonstrated initiative by routing urgent social needs such as lack of medicine, home health care, and food insecurity to Care Manager for further evaluation.
- Actively researched community resources for mental health, financial and medical needs for members. Updated staff on new programs discovered to educate members
- Educates members on health maintenance and assist members in obtaining health and well-being goals
- Provides compassion and therapeutic communication to members in acute crisis situation. Actively demonstrated effective communication to safely obtain assistance for member
- Effectively multitasked on multiple computer applications daily
- Utilized Humana Electronic Medical Record to document calls and patient demographics
- Utilized medical knowledge to properly document calls, forward members to appropriate resources and to educate members
- Answered members questions regarding care management services or general questions.
Patient Intake Specialist
University Of North Carolina Medical Center
10.2021 - 02.2022
- Completes Insurance verification in EPIC using Real Time Eligibility
- Completes Medicare Secondary Payer Questionnaire
- Balances Cash draw
- Ensures and verifies key information to ensure charging, coding, and billing accuracy
- Completes governmental, regulatory, financial, and contractual forms according to CMS Guidelines
- Utilizes Electronic Medical Record EPIC to enter medical information, Patient Demographics and Insurance Information
- Handles a variety of third-party payors such as Medicare, Tricare, Medicaid, Workers Compensation Claims and Managed Care Organizations
- Reviews patient medical record to enter pertinent medical information for billing and claims purposes.
Clinical Support Technician
University Of North Carolina Medical Center
01.2020 - 10.2021
- Provided high-quality personal care services such as bathing, grooming, dressing, and feeding to ensure patient dignity.
- Utilized therapeutic communication, empathy and active listening skills to encourage and develop positive relationships with patients.
- Performed accurate documentation of patient information according to established protocols for record-keeping purposes.
- Built rapport with patients and families, providing emotional support during difficult times.
- Managed incoming calls and directed to appropriate department.
- Supported hospital compliance efforts by adhering to privacy policies and HIPAA regulations when handling sensitive patient information.
- Organized paperwork such as charts and reports for office and patient needs.
- Improved unit workflow by effectively prioritizing tasks and collaborating with team members to complete assignments in a timely manner.
- Efficiently navigated the EPIC EMR system
- Completed admissions and discharges in a timely manner
- Delivered individualized patient care by recording vital signs, documenting observations, administering treatments, and evaluating patient needs.
- Served as a liaison between patients, families, and medical staff to ensure clear communication and understanding of treatment plans.
- Contributed to successful discharge planning through coordination with social services and rehabilitation facilities as needed.
Education
Bachelor of Arts - Psychology
Winston Salem State University
Winston Salem North Carolina 2026
High School Diploma -
Panther Creek High School
06.2017
Diploma in Certified Nursing Assistant Course
Wake Technical Community College
Raleigh, NC05.2017
Skills
- Medical Record Documentation (EPIC)
- Records Management
- Utilization Management
- Medical terminology knowledge
- Performance metrics analysis
- Medicare Guidelines
Timeline
Utilization Management Coordinator
Humana
06.2022 - 12.2022
Patient Intake Specialist
University Of North Carolina Medical Center
10.2021 - 02.2022
Care Management Support Assistant
Humana
06.2021 - 06.2022
Clinical Support Technician
University Of North Carolina Medical Center
01.2020 - 10.2021
Bachelor of Arts - Psychology
Winston Salem State University
High School Diploma -
Panther Creek High School
Diploma in Certified Nursing Assistant Course
Wake Technical Community College
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