Santrece Moore

• Analyzed and addressed escalated claims to resolve issues quickly and implemented strategies to improve claim processes.
• Checked documentation for accuracy and validity
• Worked productively in fast-moving work environment to process large volumes of claims and managed claim expenses to control costs.
• Maintained accurate and up-to-date records of claim information for future reference.
• Researched and analyzed claims to determine next steps and possible outcomes.

• Used strong analytical and problem-solving skills to develop effective solutions for challenging situations paid attention to detail while completing assignments
• Able to prioritize duties and work in a team environment
• Managed time efficiently in order to complete all tasks within deadlines and trained colleagues on multiple daily task for execution

• Prioritized work to comply with TAT’s and adhered to established performance standards.
• Process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to company policy and procedures.
• Utilized researching systems for participating physicians to assist members identify Out of Network (OON) services.
• Triaged and completed recertification request and approvals for pending Home Health Care (HHC) visits.

• Maintained accurate and complete documentation of required information that met risk management, regulatory, and accreditation requirements.
• Performed intake of calls from members or providers regarding services via telephone, fax, Electronic Data Interchange (EDI).
• Protected confidentiality of member information and adhered to company policies regarding confidentiality.

• Approved services that did not require a medical review in accordance with the benefit plan.
• Supported the administration of the recertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, while adhering to company policy and procedures.
• Promoted communication, both internally and externally to enhance effectiveness of medical management services(e.g., claim administrators, Plan Sponsors, and third party payers as well as member, family and health care team members respectively).

• Provided assistance to Inpatient Care Coordinator by requesting clinical documentation from facility Utilization Management.
• Managed of high call volumes, including clinical data collection on 23 hours observation, direct/inpatient admits, referral processing, routing calls to appropriate area and assisting with appropriated discharge planning process. Effectively managed case load of 40-60 active cases.
• Acted as Team Lead and Preceptor of Healthcare Facilitators (HCF’s) on unit.

• Maintained and reconciled HMO Bed Day Census and daily counts.
• Triaged and managed incoming cases for proper facilitation.
• Identified and accessed cases for Case Management/Disease Management referrals.

• Developed relationships with facility medical records personnel to obtain discharge dates.
• Triaged and managed incoming cases for proper facilitation.
• Requested additional clinical information from providers to update claim status.

Additional Info upon Request

Additional Info upon Request