Moya Gayle Coleman

• Managed end-to-end utilization review and complex prior authorizations within NextGen, securing complete medical necessity justification for specialized diagnostics and advanced imaging.
• Utilized specialty authorization channels including eviCore, Carelon, and Cohere for submitting clinical data packets and tracking real-time approvals, enhancing workflow efficiency.
• Audited provider charts to extract and cross-reference clinical data against commercial and Medicare criteria, leading to a reduction in initial determination denials.
• Enforced meticulous data integrity, triage documentation, and strict HIPAA compliance during high-volume multi-site records sharing, ensuring regulatory adherence.

Executed clinical and financial clearance pipelines using Epic and eClinicalWorks, ensuring timely insurance eligibility checks and coverage verification for pain management and primary care populations.

• Coordinated complex outbound specialty tracking, packaging structured clinical documentation to secure expedited external coverage approvals.
• Coordinated outbound specialty tracking and packaged structured clinical documentation, securing expedited external coverage approvals.
• Audited medical charts for medical necessity guidelines, facilitating accurate submissions of task queues and follow-up notes to managed care networks.

• Optimized administrative workflows within fast-paced clinical environments, processing remote patient intake, data entry, and provider queues.
• Streamlined administrative workflows in fast-paced clinical environments by processing remote patient intake, data entry, and provider queues, enhancing overall operational efficiency.
• Acted as primary operations liaison for emergency care networks, auditing patient chart summaries to transmit secure data packets between facility systems.

• Identified patient financial responsibility variables, pre-certified primary care diagnostics, and managed accurate medication reconciliation logs to prevent coding loops.
• Resolved backend bottlenecks by tracking historical claims and following up with insurance providers, specialist networks, and diagnostic centers to streamline claims processing.
• Tracked patient financial responsibility variables and pre-certified primary care diagnostics. Maintained medication reconciliation logs to ensure accurate billing.