Provide comprehensive healthcare management to facilitate delivery of appropriate quality healthcare, promotes cost effective outcomes and improves program/operational efficiency involving clinical issues. Support comprehensive coordination of medical services including Care Team intake/triage, screening and supporting the implementation of care plans to promote effective utilization of healthcare services. Engage and active in the growth and best practices of being a Preceptor, using quality and feedback tools. Subject matter expert for healthcare delivery programs for unit. Organize a variety of administrative and clinical tasks, and prioritize them in order of importance and impact on members and providers. Maintain accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements. Consistently receive monthly audit scores of 100% for case and telephone audits. Interact with other departments including Claims, Intake, Enrollment and Member Services to resolve member and provider issues. Perform precertification reviews of incapacitated children requested by members and plan sponsor liaisons. Perform triage, review, and authorization or denial of medical and surgical services as requested from providers telephonically and electronically. Complete retrospective reviews of claims for services requiring precertification. Assist in the research and resolution of claims payment issues. Consistently meet all scorecard objectives, and achieve “Highly Successful Performance” rating. Assign work shifts and job assignments for team. Review medical records electronically and file for backend imaging. Active participant in the Dedicated Unit Newsletter, Aetna Culture Minions, and Retro workgroups. Generate multi system reports for management that are imperative to daily company operations. Active member of the Employee Resource Group. Volunteer for company sponsored events for charity.

Performed non-medical research pertinent to the establishment, maintenance and closure of open worker’s compensation cases.Provided support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems.Coordinated service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members.Provided literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word. Participated and supported nursing tasks, including but not limited to: faxes, discharge preparations, request of clinical information, and creation of authorizations if necessary.

Enforced merchandising and loss control strategies.Executed corporate programs, policies, and promotions.Assisted and directed new store openings in NE OH region with District Manager.