Tia Gaines
Summary
An organized and motivated individual, eager to utilize time management and organizational skills across diverse settings. Seeking entry-level opportunities to enhance abilities while contributing to company growth.
Overview
8
8
years of professional experience
1
1
Certification
Work History
Utilization Review Coordinator/Remote
Blue Cross Blue Shield
02.2019 - Current
- Expert in evidence-based criteria, including InterQual and Milliman Care Guidelines.
- Track authorization status inquiries for timely response.
- Submits authorization and referral requests to health plan via avenue of insurance requirement.
- Including, but not limited to, website, phone, and fax.
- Requires fundamental knowledge of the revenue cycle process, which includes such things as patient access, utilization review, charge capture, HIM, and patient accounting.
- Requires the advanced analytical and critical thinking skills necessary to audit patient care data, associated patient care documentation, and identify variances in standards of care.
- Requires knowledge of rules and regulations pertaining to hospital reimbursement.
- Requires familiarity with managed care principles and an understanding of the post-acute continuum of care.
- Reviews benefit language and medical records to assist in completion of requested services, to meet health plan requirements.
- Demonstrated effective verbal and written communication abilities in preparing documentation, drafting appeal letters, and providing education on revenue cycle process to staff and physicians
- Provides member services to all patient group.
- Analyzed opportunities to improve patient satisfaction
Referral Coordinator
Texas Health Resources
01.2018 - 01.2019
- Navigation Organizing schedules and managing appointments for patients to ensure they receive services in a timely manner
- Facilitating communication between the patient, family members, and healthcare providers to ensure patient satisfaction and quality of care
- Coordinates and processes patient referrals to completion with precision, detail and accuracy
- Schedules patient (Preferred Providers List of Specialist) and notifies them of appointment information, including, date, time, location, etc
- Accommodating interpretive language services when needed.
Team Lead/ Patient Adovcate
Medsyneries
08.2016 - 12.2018
- Coach and develop Customer Service Representatives in all areas of performance including metrics and behaviors
- Handle escalated customer issues and provide weekly function support for customer interactions
- Provide in-depth review of patient account information to answer questions regarding patient responsibility, account billing status, insurance information and charges, and etc
- Evaluate quality, track results and provide coaching for increased success
- Communicate and transfer information to clinics and other departments as applicable for resolution
- Work patient correspondence, update information, audit accounts and mail out requested information
- In-depth working knowledge of the various applications associated with the workflows
- Ensure all workflow items are completed within the set turn-around-time within quality expectations.
Education
Medical Billing Certification -
Davenport University
Skills
- Ability to Multitask
- Microsoft Office
- Attention to Detail
- Strong organizational skills
- Medical Insurance Knowledge
- Effective Time Management
- Customer Service
- Relationship and Team building
- Insurance Verification
- Excellent customer service skills
Certification
4/2024 All Lines Adjuster Certificate
Timeline
Utilization Review Coordinator/Remote
Blue Cross Blue Shield
02.2019 - Current
Referral Coordinator
Texas Health Resources
01.2018 - 01.2019
Team Lead/ Patient Adovcate
Medsyneries
08.2016 - 12.2018
Medical Billing Certification -
Davenport University
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