Accountable for monthly, quarterly, and annual state reports for submission to Texas Health and Human Services Commission and Texas Department of Insurance including Out of Network Reporting, network adequacy filings, analyze reports for areas of improvement needed for reporting to senior management.

Respond to network inquiries including provider requests (e.g. policy and procedures,credentialing status, claims status, provider leads,ext)Obtain delegated credentialing material and coordinate processesAct as intermediary between plan and providers to record provider complaints and actively work to resolve provider issues i.e. claims,recoupments, pending cliam reports, member complaints

Evaluate members for social service programs appropriate for seniors.Consulted with doctors,therapists, and medical professional regarding intervention and social and mental needs for members.traveled to hospitals and skilled nursing facilities to discuss end of life care options for seniors.

Assisted clinical care manager in both utilization and disease management for the integration and coordiantion of patient care.Assisted with supporting patient compliance with treatment plans, which lowered readmission rates.Authorized observation/inpatient hospital stays per day including home health, skilled nursing, occupational therapy, speech therapy,DME equipment.Worked closely with hospitalists physician's offices, hospitals, and skilled nursing facilities to provide authorizations for approprate level of care.

Assisted supervisor with admission information,transcribed doctors' orders and consults on Kardex and Medication Administration Records for new admissions.Compete lab request forms and scheduled family apopintments for diagnostic exams.Provided information to other departments, families, and staff regarding patients.Provided supportive services to mental health client's including paticipation in and leading various groups.