Connie Temple Email and Phone Number

Manage member case load for annual and proactive HEDIS/prenatal-postpartum (PNPP) compliant/non-compliant population. Retroactive medical record review to obtain clinical quality data per HEDIS/prenatal-postpartum (PNPP) specifications set forth by the National Committee for Quality Assurance (NCQA). Medical record data abstraction for all HEDIS measures through EMR's and PCP to collect criteria established by CMS, NCQS and other regulatory agency standards. Independently reviews targeted measures and accurately document relevant medical record data into the Quality database. HEDIS auditor and Overreader for annual audit.

Conduct medical record reviews including physican progress notes and radiology reports, Entered data, generated reports, and produced tracking documents. Enhanced operational workflows by maintaining well-organized documentation systems and updating records accurately as needed. Gathered and organized materials to support operations. Tracked records and maintained communication between clients and health care specialist.

Performed initial, concurrent and retrospective utilization reviews for all behavior health inpatients. Collaborated with physicians and social workers to obtain required clinical information to support medical claim. Contacted insurance carriers to obtain authorizations. Managed physician peer review and appeal processes pertaining to denials and potential denials as outlined by insurance carriers. Provided ongoing reviews of patient conditions and/or improvements in accordance with insurance carrier. Complete coordination of benefits and bridge on discharge.