Tina Cole
Newport News,VA
Summary
Utilization Management Technician with comprehensive experience in concurrent and retrospective reviews, and prior authorizations. Adept at utilizing Microsoft Office and SharePoint for efficient workflow management, while ensuring compliance with regulatory standards. Engages effectively with clinicians and providers to resolve inquiries and support healthcare delivery.
Overview
21
21
years of professional experience
Work History
Remote Utilization Management Technician
AmeriHealth Caritas
Washington, DC
03.2010 - Current
- Managed the authorization process for inpatient and outpatient services according to established guidelines for various business lines.
- Facilitated daily operations of Utilization Management, Concurrent Review, Retrospective Review, and Prior Authorization teams by coordinating effectively with staff, facilities, vendors, and providers.
- Effectively coordinates Peer to Peer discussions between Clinicians and Insurance companies.
- Compiled organized, detailed summaries of prior authorization requests to streamline post-claim denial workflows.
- Maintains current knowledge base in AMC systems and programs to appropriately document case activity.
- Performs in call center environment appropriately processing or triaging calls from providers.
- Completed acquisition of DC Chartered Health Plan as a Remote Utilization Management Technician.
Concierge- Front Desk Attendant
Cleaning Resources, Inc
Alexandria, VA
06.2017 - 06.2019
- Delivered Class “A” customer service by building rapport with residents and consistently exceeding expectations.
- Meet and greet all visitors such as residents, guests and prospects.
- Respond to tenant questions and complaints in a timely manner.
- Ensure that only authorized individuals enter the building.
- Manage incoming phone calls and direct them to appropriate destination.
- Oversaw resident packages and mail, ensuring timely scanning of incoming and outgoing items.
- Coordinate reservation for amenity space, loading elevators and loading dock.
- Performed daily building inspections, identified maintenance issues, arranged furniture and décor, and upheld cleanliness standards.
- Stay in compliance with fair housing regulations.
Adverse Determination Manager- Trainer
DC Chartered Health Plan, AmeriHealth Caritas
Washington, DC
03.2010 - 04.2013
- Ensured compliance with all regulatory and accreditation standards related to departmental adverse determinations.
- Updated knowledge of NCQA, URAC standards, and District of Columbia regulations to ensure compliance with adverse determination processes.
- Achieved performance standards for accuracy and timeliness in adverse determinations, contributing to operational reliability.
- Scanned all determination letters into SharePoint for sufficient access.
- Coordinated acquisition of office supplies and business cards, ensuring operational readiness for Medical Management.
- Processed check requests and requisitions for supplies.
Assistant Program Manager
Comprehensive Health Services, Inc
Reston, Virginia
08.2005 - 06.2009
- Partnered with BNSF Program Manager to manage project including timeline, work plan, testing, resources, training and documentation of procedures.
- Communicated project goals to all management levels and provided appropriate and timely resources for efficient and effective project completion.
- Managed departmental operations during program manager's absence and approved timesheets weekly in Deltek to maintain workflow continuity.
- Facilitated daily communication with the hiring department for BNSF Burlington Santa Fe Railroad and DHS-CBP.
- Coordinated and expedited occupational health exams, federal drug screen results, and psychological exams to ensure timely processing.
- Provided timely and accurate status of account information in response to inquiries from Medical Hiring Center (MHC) for BNSF.
- Direct contact with client Burlington Northern Santa Fe Railway to ensure that all examinees for BNSF positions were handled in suitable 14-day timeframe.
- Processed Customs and Border Protection requests within 28 days and oversaw monthly invoicing for medical exams to ensure compliance and timely billing.
Education
High School Diploma -
Wakefield High School
Arlington, Virginia04-2026
Administration Assistant and Secretarial Services Certification -
Northern Virginia Community College
Alexandria, VirginiaOffice Administration Certification -
Northern Virginia Community College
Annandale, VASkills
- Medical coding principles
- Health systems management
- Jiva software
- CHCS software
- Medi-Elites software
- Medisoft program
- CBSI application
- Optix software
- Healthcare communication systems
- Microsoft Office Suite
- Spreadsheet management
- Word processing
- Presentation software
- SharePoint collaboration
- Personnel management system
- Exam tracking system
- Typing speed 50 WPM
References
- Barbara Stallans, UM Nurse, (202) 577-4550
- Kenya Broadnax, UM Supervisor, (202) 258-3009
- Chanel Lynn, Billing Specialist, (202) 607-7939
Timeline
Concierge- Front Desk Attendant
Cleaning Resources, Inc
06.2017 - 06.2019
Remote Utilization Management Technician
AmeriHealth Caritas
03.2010 - Current
Adverse Determination Manager- Trainer
DC Chartered Health Plan, AmeriHealth Caritas
03.2010 - 04.2013
Assistant Program Manager
Comprehensive Health Services, Inc
08.2005 - 06.2009
High School Diploma -
Wakefield High School
Administration Assistant and Secretarial Services Certification -
Northern Virginia Community College
Office Administration Certification -
Northern Virginia Community College