Melissa Diaz
Cypress,USA
Summary
Reliable and detail-oriented healthcare administration professional with over 10 years of experience supporting high-volume clinical operations, utilization review, and referral authorization. Proven ability to streamline office procedures, maintain HIPAA compliance, and collaborate across multidisciplinary teams. Skilled in Epic, Cerner, RightFax, and payer portals, with a strong ability to prioritize tasks in fast-paced environments.
Overview
14
14
years of professional experience
Work History
UM Coordinator
HealthSmartMso
03.2024 - Current
- Facilitated all UM referral activities for assigned medical groups, ensuring accuracy and timeliness.
- Processed referral authorization requests via EHealth, both faxed and electronic submissions.
- Coordinated necessary services among health plans, CCS, and case management teams.
- Generated and approved authorizations in compliance with business rules.
- Managed daily inquiries from providers regarding authorization status or modifications.
- Dispatched referral notifications to providers and health plans promptly.
- Verified member benefits and eligibility upon receipt of treatment authorization requests.
- Utilized authorization matrix and ancillary rosters to inform decision-making.
Utilization Review Assistant, IP
Long Beach Memorial Medical Center
04.2022 - 03.2024
- Secured authorizations by determining and transmitting chart documents to health plans promptly.
- Conducted admission, continued stay, and discharge reviews for all managed care and private insurance clients.
- Documented all activities and authorizations in accordance with standard work protocols.
- Responded to inquiries via calls, emails, and faxes related to concurrent review requests.
- Maintained compliance with HIPAA regulations to ensure patient confidentiality.
- Enhanced case management efficiency through accurate documentation, improving resource allocation and patient outcomes.
Utilization Review Assistant, OP
Long Beach Memorial Medical Center
12.2018 - 04.2022
- Coordinated patient referrals, including submission, tracking, and follow-up on all cases.
- Selected appropriate chart documents to submit requests for government insurance and private health plans.
- Navigated payer portals to transmit authorization requests efficiently.
- Provided clerical support, including triaging calls, mailing, faxing correspondences, and printing reports.
- Verified patient eligibility and obtained detailed benefit plan information.
- Conducted daily status calls to payors for updates and modifications to authorizations.
- Maintained accurate records of activities related to all authorization requests.
- Performed additional duties as assigned.
Clinical Representative I
Children's Hospital Los Angeles
12.2011 - 09.2017
- Verified insurance coverage and authorized lab visits with Managed Care Groups and CCS.
- Maintained rapport with families of inpatient and ambulatory patients.
- Developed front office clinic workflow to enhance efficiency and minimize wait times.
- Coordinated patient appointments with lab and radiology requests to optimize scheduling.
- Managed billing processes, including answering multiple phone lines and handling correspondence.
- Supported clinical operations by updating daily clinical schedules to meet targeted volumes.
- Served various roles within Pediatric Surgery, including Financial Counselor and Scheduler, to provide administrative support.
- Utilized communication skills to empathize with patients, exceeding their expectations.
Education
Licensed Vocational Nurse
American Career College
CA02-2026
GED -
Skills
- Referral & Authorization Management
- Utilization Review (Inpatient & Outpatient)
- Case Coordination CCS Experience
- Health Plan & IPA Communication
- HIPAA Compliance Data Entry
- Microsoft Office (Word, Excel, Outlook, PowerPoint)
- Epic Cerner RightFax
- Typing: 75 WPM with accuracy
- Customer Service Problem Solving
- Bilingual: English / Spanish
Timeline
UM Coordinator
HealthSmartMso
03.2024 - Current
Utilization Review Assistant, IP
Long Beach Memorial Medical Center
04.2022 - 03.2024
Utilization Review Assistant, OP
Long Beach Memorial Medical Center
12.2018 - 04.2022
Clinical Representative I
Children's Hospital Los Angeles
12.2011 - 09.2017
Licensed Vocational Nurse
American Career College
GED -
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