Customer Service Utilization Management
Resume:
DENEEN DOGAN 267-***-****
E- Mail: ad2gfj@r.postjobfree.com
PROFESSIONAL EXPERIENCE
Keystone First/AmeriHealth Caritas
Concierge Coordinator 1-21 to Present
Management of the customer relationship by providing customized interaction based on member needs creating a connection to ensure retention and maintain member loyalty.
Provide member education and counseling on access to services, benefits and providers.
Resolve member concerns providing resolution within expected or required timeframes.
Complete welcome calls for member that are newly enrolled with the plan including scheduling initial assessment for Medical Management as required by contract.
Responsible for record keeping, documenting call dispositions and/or compiling and generating reports as required.
Keystone First/AmeriHealth Caritas
Grievance/Appeals Specialist 10-20 to 3-21
Assist member or provider, or provider on behalf of the member, in filing a formal appeal and grievance.
Provides superior customer service to clients, members, providers, facilities etc.
Coordinates and handles all member and provider appeals and grievances, including the member grievances, appeals, requests and disputes.
Researches and resolves complaints in collaboration with the Quality Assurance Supervisor and General Manager.
Identifies deficiencies and develop corrective action plan to ensure compliance is met
Keystone First/AmeriHealth Caritas
Community Health Navigator, Member Outreach 07-17 to 3-21
Recommend products and services to members and accurately explained details of services offered.
Cross-train and provide back-up for other customer service representatives when needed.
Manage wide variety of customer service and administrative tasks to resolve customer issues quickly and efficiently.
Informs members of the required actions to fulfill HEDIS, and Plan requirements and other referred outreach, through phone calls or home visits, and encourages them to comply.
Assist in addressing members’ barriers to care and to encourage/foster relationships with their medical/dental providers (medical/dental homes).
Keystone First/AmeriHealth Caritas
Utilization Management, Utilization Management Technician, 2015 to 2017
Supported the daily operations of care coordination and u Utilization Management. Concurrent review, retrospective review with prior authorization teams through interaction with staff, M/C, facilities, vendors and providers.
Reviewed clinical information and records to perform utilization review assessing, monitoring and evaluating patient care for medical necessity for inpatient admissions utilizing internal criteria and company care guidelines.
Interfaced with medical facility multidisciplinary personnel to assess and direct discharge planning for patients.
Certified and reviewed material that meet clinical review criteria/guidelines.
Maintained compliance with regulatory changes affecting utilization management.
Coordinated physician reviewer referral as needed and follows up timely to obtain and deliver those results.
Keystone First/AmeriHealth Caritas,
Retention Department, Care Connector, 2012 to 2015
Explained and applied hospital and federal policies and regulations to ensure proper patient care
Utilized knowledge of the healthcare field by explaining insurance coverage benefits and medical care cost to patients
Managed incoming phone calls and resolved patient inquiries and referred calls to appropriate departments
Corrected patient's Demographic data, scheduled appointments, Confirmed Referrals and Surgeries utilizing internal systems daily
Communicated with corporations, insurance and Pharmaceutical companies via telephone or correspondence
Responsible for determining at risk members need for case management.
Scheduled members for appointments to important health screenings such as mammograms, pap smears, eye exams and blood pressure testing.
Resources for Human Development,
The Residential Job, Residential Aide, 2006 to 2013
Responsible for management of an 18-client household including housekeeping and health care tasks such as doctor appointments, meal preparation and other related support services essential to client’s health
Adhered to precise procedures and standards involving a high degree of accuracy in observing clients
Promoted healthy behaviors and disciplines in clients through positive interactions, such as daily problem-solving decisions
Effectively managed emergency situations by identifying potential crises and resolving them for maximum client safety
Successfully modeled positive social skills and healthy interpersonal relations to at-risk clients
Created personal goals for clients and continually counsels each on steps to reach the goals in place
EDUCATION
2018-2020- Peirce College, Bachelor in Business Management
1994-1998-Audenried High School, General Studies
CERTFICATIONS
2020 Community Health Worker
References Available Upon Request
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