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Utilization Specialist Resume

Houston, TX

SUMMARY:

Experienced Healthcare Analyst with more than 8 years’ experience with Medicare/Medicaid within hospital and managed care. Seeking full time role with dynamic organization in the Greater Houston, TX area or remote.

SKILLS:

Care One, Microsoft Operating Systems, Cerner, Facets, EDI data transfer, Health Quest, ICD - 9,10, COGNOS, Macess, Adobe Reader, 10 Key touch, Macro Express Pro

EMPLOYMENT HISTORY:

Confidential, Houston, TX

Utilization Specialist

Responsibilities:

  • Processed health plan utilization authorizations with accuracy
  • Responsible for the initiation of concurrent/ inpatient cases by data entry of clinical, demographic and product information into the Medical Management system, fax or online portal
  • Utilized EDI to ensure the proper hospital admission information was updated for Harris Health system and compared utilization requests accordingly
  • Handled data entry of all notifications of admission, transfers, and assist with the requests for home health, and durable medical equipment
  • Coordinated and attend calibration sessions as required
  • Collaborated with the management and reporting team to ensure accurate submission of regulatory reports, corrective action plans and compliance - based reports such as Key Performance Indicators (KPIs), as required
  • Assisted in the creation, maintenance, and revision of all operational clinical processes and workflows
  • Collaborated with systems and reporting teams to ensure written requirements are effectively implemented and maintained in documentation tools
  • Assisted leadership with associated administrative processes to ensure cohesiveness across departmental functions and delegated entities
  • Responsible for accurate case completion /quality and productivity standards while staying within compliance timeframes
  • Handled provider outbound calls according to departmental standards

Confidential, Houston, TX

Revenue Cycle Customer Service Representative /Claims resolution/Accounts Receivable

Responsibilities:

  • Reconciled patient accounts for bill resolution and payments
  • Utilized EDI to ensure the hospital admission was updated according to HIPPA and review claim status
  • Medicare billing and commercial account follow-up utilizing Health Quest and cross-referencing when needed in Cerner
  • Assigned appropriate medical codes and developed training material for new employees regarding the claims process
  • Answered patient calls in a timely matter and directs them to the proper department when necessary
  • Utilized Health Quest to process patient data, including payments and insurance verification
  • Investigated medical records to determine pre-existing medical conditions Verified claims for adjudication when needed
  • Analyzed claims reports in Facets for key stakeholders
  • Processed claims entry and management of claim processing for the medical group
  • Reeducated patients on Explanation of Benefits forms and steps for authorization of services

Confidential, Houston, TX

Administrative Coordinator

Responsibilities:

  • Provided appeals and grievance regulations for Medicare Advantage, Part D, and Medicaid plans
  • Utilized EDI to update hospital admission information as needed
  • Worked with EDI systems to ensure the proper communication regarding provider hospital communications and credentialing updates
  • Identified and help resolve claims issues for Medicaid and Medicare Department
  • Medicare billing and commercial account follow-up
  • Contacted providers to create and update proper Emergency Room authorizations and admissions
  • Provider network database updates
  • Supported clinical staff with daily tracking logs
  • Provided support to patients and former patients for bill resolution and payments
  • Verified and support the patient services team for all clients
  • Tracked employee hospital admissions for Confidential Hospital System
  • Researched complaints to determine appropriate action

Confidential, Houston, TX

Team Lead

Responsibilities:

  • Trained team regarding claims and processing protocol in Facets
  • Provided direct supervision to the claims team
  • Provided Medicare and Medicaid account claim follow-up for northeastern United States markets
  • Performed post-training follow up and review for performance management
  • Monitored and audits specified criteria based on claims training to assure perception of policy and procedures guidelines was comprehended
  • Verified EDI requests to ensure the proper transfer of data regarding appeals decisions with member benefit eligibility
  • Compiled and reviewed internal reports to identify any incorrect claims payment for all product lines for the weekly check run
  • Mastered appeals and grievance regulations for Medicare Advantage, Part D, and Medicaid plans within Facets platform

Confidential, Houston, TX

Administrative Coordinator

Responsibilities:

  • Identified opportunities that impact quality goals and recommend process improvements for the Medicare Claims department using Facets and Macess
  • Assigned appropriate medical codes with a 98 percent accuracy rate
  • Assisted claims manager with reporting for weekly metrics and identifying errors
  • Analyzed multiple claims according to Medicare and Medicaid standards within CMS
  • Analyzed existing systems to resolve problems
  • Worked with IT to identify design and implementation issues for process flows and implementation
  • Updated and reviewed Facets claims data including Provider updates and communicate with the Provider Relations Department

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