Tonya Williams

• Reviewed patient records to ensure compliance with care protocols.
• Monitored care plan progress, adjusting strategies to enhance patient outcomes.
• Participated in quality improvement initiatives to enhance patient care delivery.
• Managed patient referrals, connecting members with appropriate healthcare services and specialists for optimal care.

Analyzed new referrals for member eligibility based on claims data and medical conditions, directing them to suitable case management programs.

Collaborated with nursing team to effectively manage 65+ active case loads across various lines of business.

Assisted case managers in coordinating patient care by distributing educational materials and forms.

Verified member eligibility across all lines of business, including EHP and Tricare.

• Maintains medical records in accordance with the SNF (Skilled Nursing Facility)
• Ensured accurate maintenance of active and discharge medical records
• Increased the safeguards medical information against loss, destruction, or unauthorized use
• Streamlined retrieval system for discharge medical records, organizing thinned files for efficient access and integrity of resident medical records
• Processed requests for medical records copies from attorneys and medical facilities while adhering to HIPAA regulations and applicable laws.
• Documented all requests for medical records to ensure compliance with regulations.
• Monitored closed chart process for discharged clinical records, managing Discharge Chart Control Log and off-site records storage log
• Pulled patient records and transferred information to appropriate parties.
• Maintained electronic medical records for all clients
• Verified record copies before handing each over to check for and remove unnecessary details.
• Scanned incoming documentation.
• Maintained complete confidentiality in accordance with organization and legal requirements.

• Analyzed new referrals to determine member eligibility for case management based on claims data, diagnosis, and medical conditions and refer to appropriate case management program (context/number show many/often) phone/electronic referrals
• Collaborated with nursing team to manage active case load of 65+ cases across multiple lines of business, including Priority Partners, Johns Hopkins Advantage MD, EHP, and Johns Hopkins US Family.
• Coordinated patient care by distributing educational literature, welcome packets, advance directives, and consent forms to enhance member understanding and engagement.
• Verify member eligibility for all lines of business including EHP, Tricare, Johns Hopkins AdvantageMD, and Priority Partners
• Worked as an Epic superuser, and proficient using Maryland Medicaid Eligibility Verification System (EVS)
• Conduct Patient Activation Measures (PAM surveys) and SF-12 Surveys telephonically and score surveys using Flourish and AM-I-Healthy database
• Determine Proper ICD-9 and CPT coding for authorizations
• Coordinated patient care and provided case management services to diverse populations, including adults, pediatrics, maternity, behavioral health, and elderly.
• Coordinate various member service including requests for durable medical equipment, home health services, and specialty visits
• Compose and generate patient, case managers, and physician mailings
• Collect data, review and work daily reports
• Train and orient new employees.

• Provided guidance and assistance in disease case management programs for complex medical inquiries.
• Coordinated patient referrals for the Partners with Mom program
• Reviewed Maryland Prenatal Risk Assessments (MPRAs) to determine member eligibility for case management, and entered into the maternity database
• Collected data and issued monthly reports to Department of Health and Mental Hygiene and Local Health Department, supporting ongoing analysis of case management effectiveness.
• Reviewed and managed incoming Health Risk Assessments (HRAs) for completeness and accuracy, ensuring compliance with case management standards.
• Maintained and entered complex data in the disease management databases
• Coordinated member and physician communications by processing mail, faxes, and incoming documents to facilitate timely information exchange.
• Distributed health education information to members using disease-specific literature
• Verified member eligibility for all lines of business
• Streamlined & used multiple internal and external systems including IDX, EPR MSR MC400, SharePoint, and multiple disease management database.
• Cooperated with local service providers, outreach workers, case managers and collaborative agencies to facilitate services for members.
• Protected patient data in alignment with HIPAA privacy protocols.