Starlette Franks

Provides timely and appropriate resolutions to escalated issues received from various communication channels

Serves as a liaison in maintaining relationships between departments to ensure timely and appropriate issue resolution

Documents, tracks, resolves, and responds to all assigned complaints and inquiries in writing and/or by telephone in a timely and professional manner

Conducts and monitors root cause of member or provider issues to identify trends across the enterprise, and works cross functionally with all departments to ensure enterprise-wide solutions

Coordinates with contact center team to research and review underlying facts of escalated inquiries, determine validity of complaints, and evaluate options to remedy these complaints

Performs other duties as assigned

Complies with all policies and standards

Gather, analyze and report verbal and written member and provider complaints,grievances and appeals

Prepare response letters for member and provider complaints, grievances and appeals

Maintain files on individual appeals and grievances

May coordinate the Grievance and Appeals Committee

Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information

Assist with HEDIS production functions including data entry, calls to provider’s offices, and claims research.

Manage large volumes of documents including copying, faxing and scanning incoming mail

Performs other duties as assigned

Complies with all policies and standards

Assesses and analyzes member insurance coverage and/or service/benefit eligibility via system tools and aligns authorization with the guidelines to ensure a timely adjudication

for payment

Reviewed authorization requests to ensure authorization requests are documented in the utilization management system and are in accordance with policies and procedures

Developed in-depth knowledge of prior authorization review process and insurance coverage including responding to complex or escalated authorization requests

Maintains ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines

Act as a subject matter expert as well as a trainer to other team members for the overall authorization process and for multiple service types at different levels of urgency

Oversees the authorization review process of utilization management team members

researching and documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination

Assists with aging reports and audits

Reviews escalations and works on resolving them in a timely manner

Assists with reporting on authorization volumes and alignment on staffing assignments

Ensures referrals are addressed in a timely manner by service providers and clinical reviewers

Leads, oversees, and maintains authorization requests for services in accordance with the insurance prior authorization list

Remains up-to-date on healthcare, authorization processes, policies and procedures

Expert knowledge of medical terminology and insurance

Performs other duties as assigned

Complies with all policies and standards

Gather, analyze and report verbal and written member and provider complaints, grievances and appeals

Prepare response letters for member and provider complaints, grievances and appeals

Maintain files on individual appeals and grievances

May coordinate the Grievance and Appeals Committee

Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information

Manage large volumes of documents including copying, faxing and scanning incoming mail

Performs other duties as assigned

Complies with all policies and standards

Supports authorization requests for services in accordance with the insurance prior authorization list

Supports and performs data entry to maintain and update authorization requests into utilization management system

Assists utilization management team with ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines

Contributes to the authorization review process by documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination

Remains up-to-date on healthcare, authorization processes, policies and procedures

Performs other duties as assigned

Complies with all policies and standards