Summary
Overview
Work History
Education
Skills
Timeline
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Tiffany Robinson

Fairburn,GA

Summary

Dependable Utilization Management Coordinator promoting over 10 years of expertise in the healthcare industry. A seasoned professional offering proven clinical knowledge, strong interpersonal skills, and extensive knowledge. Specializing in Case management, medical/surgical, rehabilitation, and home health care.

Overview

14
14
years of professional experience

Work History

Utilization Management Administrative Support

Avesis (TotalMed)
01.2023 - Current
    • Review and key in new and correct dental and vision preservice requests submitted by providers into Avesis' processing system
    • Check for accuracy and completeness if insufficient draft notifications to providers for correction and resubmission
    • Perform outreach to providers for correction and resubmission if a request is submitted with insufficient information
    • Create ad-hoc manual letter requests utilized to communicate with enrollee and/or provider
    • These communications are time sensitive and must meet regulatory, accreditation, or contractual requirements
    • Handle clerical support for the department, including but not limited to receipt and response of incoming and outgoing fax, email transmissions both internal and external, draft/upkeep meeting agendas, meeting minutes
    • Pull and report daily logs of processed preservice request for special facility setting review and forward to external contacts for authorization
    • Support UM leadership and Avesis' communication team in the review and routine maintenance of letter template library for accuracy.

UM Intake Care Specialist

Emblem Health
03.2022 - 08.2023
  • Effectively communicate changes or trends in insurance policies to team members
  • Obtain pre-authorization from insurance carriers for medical services within designated time frame.
  • Follow up and secure prior authorizations prior to service appointments.
  • Demonstrate proficiency in medical terminology and general medical office procedures, including HIPAA regulations
  • Maintain productive work rate suitable for the department
  • Record all communication with providers and personnel in standardized documentation with the proper format
  • Review denial reasons and advocate for patients while obtaining approval/denial letters, informing the office of results, and providing appeal services
  • Build relationships with physician offices and clinics by initiating contact via email, answering phone/email correspondence promptly, and responding within one business day.

Customer Service Supervisor

Randstad/Alight
08.2020 - 06.2022
  • Coordinate and supervised daily/weekly/monthly team activities of team members
  • Set priorities for the team to ensure task completion and performance goals were met
  • Identified and resolved operational problems using defined processes, expertise judgment
  • Provide coaching, feedback, and annual performance reviews as well as formal corrective action
  • Manage and perform payroll corrections.

Patient Escalations/H.I.C.S.

Florida Blue
07.2016 - 03.2019
  • Member of research team working to decrease team inventory of open cases and resolve issues for members and providers within 72 business hours with CMS Demonstrates the ability to use sound judgment and discretion regarding confidential information
  • Reviewed escalations and complaints on all media (phone, email, social media and congressional levels) and managed through to resolution/satisfaction of the customer
  • Reviewed and verified information on insurance applications and policies
  • Documented pertinent patient information and all work activity in the appropriate systems dictated by company policies and procedures
  • Ensured accounts are processed in accordance with Eligibility Program standards, Client expectations, and federal and state regulations including but limited to, Health Insurance Portability and Accountability (HIPPA) guidelines.

Pharmacy Service Representative Team Lead

Aetna Specialty Pharmacy
02.2012 - 09.2015
  • Verified patient eligibility, completed insurance changes, and communicated patient coverage information
  • Performed follow-up services with members and providers including but not limited to claims, benefits, prior-authorizations, and billing
  • Evaluated claims reimbursed to the pharmacy against the pharmacy's prescription records and analyzed discrepancies
  • Cleared all rejected claims to ensure shipment on patients' medication in a timely manner
  • Determined appropriate delivery method, scheduled deliveries with patients and medical offices
  • Handled escalated calls to assist with claim rejections, delivery of medication, prior authorization.

Administrative Assistant

The CSI Companies
03.2010 - 02.2013
  • Provide general administrative support, including the creation of email correspondence, memos, and the compilation and creation of statical reports on behalf of the department
  • Review clerical ad personnel records to ensure accuracy, completeness, and timeliness
  • Maximize office productivity through the proficient use of appropriate software applications and research and develop additional resources to create timely and efficient work-flow
  • Answer inquiries, use discretion in handling difficult calls and route to appropriate individuals
  • Maintain calendars for supervisor and department
  • Coordinate meetings and ensure meeting materials are prepared
  • Monitor the status of ongoing project and maintain contact with customers and outside vendors.

Education

Associate of Science -

Florida State College At Jacksonville
Jacksonville, FL
05.2026

Skills

  • Medical Terminology
  • EMR
  • ICD - 10 codes
  • Data Entry
  • Utilization Management Administrative Support
  • HIPAA Compliance Understanding
  • Medicaid knowledge
  • Medicare knowledge
  • Insurance Verification
  • Critical thinking abilities
  • Conflict resolution techniques
  • Documentation accuracy
  • Decision Making Aptitude

Timeline

Utilization Management Administrative Support

Avesis (TotalMed)
01.2023 - Current

UM Intake Care Specialist

Emblem Health
03.2022 - 08.2023

Customer Service Supervisor

Randstad/Alight
08.2020 - 06.2022

Patient Escalations/H.I.C.S.

Florida Blue
07.2016 - 03.2019

Pharmacy Service Representative Team Lead

Aetna Specialty Pharmacy
02.2012 - 09.2015

Administrative Assistant

The CSI Companies
03.2010 - 02.2013

Associate of Science -

Florida State College At Jacksonville

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Tiffany Robinson