Medical Management Coordinator Resume Samples

Description :

1. Knowledged of all BCBS of KC computer systems for utilization management entry.
2. Prepared documents in the Utilization Management System for a prior authorization or predetermination request requiring review by a Managed Care Specialist so documentation of the demographic data and eligibility data.
3. Sent health assessments received for special programs to appropriate staff members.
4. Communicated with providers and/or members on a daily basis those request not requiring prior authorization or those which are not a request for predetermination I interpret benefits for members, providers, and internal customers.
5. Sent health assessments received for special programs to appropriate staff members.
6. Did learn how to graph and blueprint in a geography class at Lincoln University in Jefferson City, Missouri after my major changed from Nursing to Business Administration.
7. Oversaw the Healthy Solutions Department in regards to coordination and implementation of health screenings, educational classes, lunch and learns, wellness activities, etc.

Experience

10+ Years

Level

Senior

Education

MS In Business Management

Description :

1. Provided clerical and administrative support for the Medical Management department.
2. Compiled weekly and monthly reports as necessary including but not limited to precertification reports, length of stay reports, diagnosis code reports, pharmaceutical reports and case management reports.
3. Kept and maintained an active and accurate list of disease management participants.
4. Maintained daily mailing logs for nurses.
5. Completed and maintained health fair documents and assure that all information is obtained and ready in order to implement health fairs in a timely manner.
6. Attended and worked health fairs.
7. Completed audits of all denials/appeals for the Medical Management department.

Experience

5-7 Years

Level

Junior

Education

B.S. In Business Administration

Description :

1. Designed, coordinated, and implemented asthma and diabetes disease management programs.
2. Created study design for effective programs.
3. Provided telephone counseling to patients for behavior modification.
4. Coordinated with various social services to provide individuals with appropriate assistance.
5. Developed patient educational materials which were mailed to each program member.
6. Provided regular follow-up to ensure patient compliance in managing their disease.
7. Able to effectively manage their disease increased their efficacy and reduced medical utilization.

Experience

10+ Years

Level

Senior

Education

Master's

Description :

1. Worded side by side with the Medical Director and nursing staff.
2. Completed all the input information for all inpatient hospitalizations and outpatient referrals, DME, and other referral services for the state of Oklahoma.
3. Conducted new hire training on Medical Management systems along with policies and procedures.
4. Updated inpatient authorizations every day for each patient to ensure hospital bills would be approved.
5. Updated system daily with clinical notes for the off-site company nurses.
6. Assisted members with medical appointments, appeals and sat on the review team with the medical director for appeal reviews.
7. Worked on escalated medical and claims issues for the Oklahoma Department of Health.

Experience

5-7 Years

Level

Junior

Education

High School Diploma

Description :

1. Monitored, budget, and utilized operational resources on a day-to-day basis.
2. Implemented and participated in program and product development, ensuring the growth of the practice.
3. Resolved all patient and or employee issues that may have occurred.
4. Assured services are in compliance with all State and Federal regulatory requirements.
5. Trained, delegated, and supervised all staff.
6. Insured the growth of the business and maintained a happy staff.
7. Used Using my 30 plus years of experience in business management and organizational skills to build and succeed in all aspects of the job.

Experience

5-7 Years

Level

Executive

Education

High School Diploma

Description :

1. Responsible for the implementation of policies and procedures relating to aspects of the Medical Management Program Perform duties supporting the core functional areas of specialist referral processing, prior authorization, diagnostic imaging scheduling, physician call triaging, appeals, auditing, and training.
2. Worked focuses on the technical support and the organization/coordination of support activities such as production, program outcomes against stated policies, standards, and objectives; and the development of training and documentation for process and performance improvement activities relevant to the Medical Management Program.
3. Assured an integrated approach to the program is fulfilled, resulting in timely scheduling of requested services, communication across the continuum of care for requested outpatient services resulting in improvement in the provision of care and services and improved satisfaction for our patients, providers, staff, and external contacts.
4. Functioned in a team environment, providing requested services in a centralized setting on behalf of the clinics.
5. Served as an expert resource to providers, specialists, and staff in regard to the specialist referral / prior authorization requirements for multiple contracted and non-contracted insurance plans, diagnostic imaging protocols which vary between the multiple facilities/sites providing this service, and processes relating to these functions.
6. Facilitated prior authorization for selected procedures as directed by the patient's insurance.
7. Ran daily reports for the Medical Director, answered phones assisting members, and updated patient care information for hospitals and physicians.

Experience

5-7 Years

Level

Junior

Education

GED

Description :

1. Prepared by the lead inpatient case manager and reconcile with daily census report.
2. Assisted in maintain accurate authorization by updating diagnosis, level of care, CPT code, admit/ discharge date.
3. Assisted case managers in care coordination as directed.
4. Assisted case manager in faxing bed inquires to skilled nursing or other types of facilities for discharge disposition under the direction of the case manager.
5. Accurately and timely communication with the hospital regarding bed day aberrancies, service/care issues, post stabilization notification, as well as financial responsibilities for OOA/OON admissions, psychiatric admission, hospice revocation or discharges, Medicare prime, and refusal to discharge or transfer.
6. Obtained prior authorization for new medication prior to patients hospital discharge.
7. Scheduled and confirmed patient's appointment including MRI, CT, surgeries, routine follow-up.

Experience

5-7 Years

Level

Junior

Education

Diploma

Description :

1. Handled over 15 major hospitals for utilization management and managed over 50 physicians in their utilization management of patients.
2. Collaborated on patient files with Physician Advisor biweekly.
3. Billed and collected for out-of-pocket payments.
4. Confirmed with doctors, hospitals, conference rooms, materials, dates, times.
5. Documented on all cases daily.
6. Wrote member guidelines, and interventions for cervical and breast cancer which served as informative reminders to ensure health.
7. Trended, analyzed, and forecasted data based on ICD-9 codes and pharmaceutical claims prioritizing those members with the highest health care utilization to enable a decrease in utilization.

Experience

2-5 Years

Level

Executive

Education

Master's

Description :

1. Helped departments align their health management programs (for both chronic disease and preventive disease) and measurable outcomes to meet and exceed the rigorous goals of achieving this prestigious accreditation.
2. Selected for Special Projects Team for the Medical Director to head the implementation of HIV/AIDS management of care for members living at Bailey Boushay House, with a focus on preventive health and disease management.
3. Assisted in any clerical task that is necessary for the functioning of the Medical Management department.
4. Provided management direction to the Leads and direct staff throughout Hillsborough Case Management programs.
5. Managed all case management program deliverables and outcomes for multiple funding sources, including monthly and annual reports.
6. Monitored performance criteria for staff members to ensure standards and goals are met within the department.
7. Ensured that all program and agency policies and procedures are consistently followed.

Experience

2-5 Years

Level

Executive

Education

High School Diploma

Description :

1. Reviewed operations of the location to ensure a high level of service quality is consistent with organization standards.
2. Provided guidance and direction to staff regarding complex client case actions.
3. Implemented existing comprehensive quality and performance improvement plans.
4. Worked collaboratively with Medical and Behavioral Health providers, community partners, and other in-house staff to meet individual clients/patient needs and retain in services.
5. Led interdisciplinary team meetings to collaborate on the delivery of services to clients
6. Promoted effective communication between departments and entities, acting as a liaison to facilitate information sharing, collaborative problem solving, and adequate provision of support services
7. Responsible for personnel actions including, but not limited to performance appraisals, leave requests, timesheets, reports, ensure adequate staff coverage at all times, and all daily activities and management direction for staff and department.

Experience

2-5 Years

Level

Executive

Education

MS