• Lead Medical Letter Writers and manage all administrative and medical necessity denial letter processes: training and maintaining workflows.• Manage Utilization Management department escalations and interact internally and externally as the non-clinical liaison within the health plan for all authorization inquiries.• Provide resources to a team of Clinical Support Coordinators.

- Performed detailed review and analysis to determine why a medical service was under review, in dispute, or was denied. - Interpreted and managed provider appeals and provider dispute resolution processes, applicable clinical guidelines, and health payer coverage policies.- Drafted and processed 20+ administrative/medical denials daily.- Managed the internal database to track the status of medical denial letters, schedule peer to peer and reconsideration requests among other communication.- Identified discrepancies and anomalies determining if denials were properly documented.- Provided resources, education and training to assist departments with requirements of: Internal policies on documentation of medical necessity for services rendered and management of documentation requests.

Supported telephonic and onsite care managers in the process of inpatient authorizations and assist with outreach to facilities regarding clinical information. Respond to internal and external provider inquiries regarding NHP and clinical administrative policies and procedures. Lead and collaborated across multiple departments in efforts to achieve success in a member care/case management.

- Worked with leadership to establish and maintain effective policies and procedures for managed care referrals, revenue cycle, and co-payment collection for the department- Served as primary resource on all departmental managed care matters; develops, implements and monitors departmental referral management processes, resource tools, and report findings on a regular basis- Represented the practice on hospital based Referral and Registration Operations committees- Worked closely with the physicians organization and the managed care office to communicate managed care principles and policies to the practice- Educated and trained administrative assistants and practice assistants in the area of Referral Management and Pre-Registration- Participated in administrative staff meetings reporting statistical referral management and pre-registration measurements and indicators, and communicating referral management information- Acted as a managed care resource on the unit to social workers, pharmacists, physicians, nurses and resource specialists for issues regarding managed care and insurance coverage, including commercial payers, Medicare, and radiology pre-certifications

Established adequate controls to ensure that approximately $1 billion in gross patient service revenue is billed to third party carriers, government programs, grants and patients, timely and accurately. Determined eligibility and obtain authorizations from third party payers for all types of admissions/procedures (e.g. Surgical Day Care, Inpatient, Outpatients) using medical software. Acted as a liaison among patients, admitting physician offices, case management, and third party payers ensuring that all third party payers' requirements are met.

Performed clerical and administrative duties. Supported a team of nurses, medical assistants along with physicians, fellows and interns on a 32-bed medical/surgical unit. Supported the admission and discharge process to maximize patient throughput. Prepared/audited medical records for presence of appropriate forms, checklists and/or consents for patients scheduled for surgery/special procedures. Managed data system that responds to patient’s calls and monitored patient safety.

- Created and distributed recruitment materials, as well as tapped into new recruitment markets- Recruited, managed and tracked member’s application, interview, and enrollment process- Supported/coordinated materials for training, prepared presentations, researched supplemental training resources and facilitated/co-facilitated trainings- Coordinated Family Involvement sessions, activities and resources for all teams- Coached members by modeling developmentally appropriate practices, conducting observation and providing feed-backs- Partnered closely with Site Managers to create self-study and professional development resources for members- Assisted teams through training, weekly meetings, follow-up communication, and resource sharing