Case Management Health Care
Resume:
LATOYA CARTER
312-***-**** ********@*****.***
Professional Summary
Results driven health care professional with over 10 years as a Program Coordinator. With a strong history of experience exceeding company goals and program objectives. Highly skilled in collecting data and providing resources and custom solutions to enhance the use of medical plan resources.
Experience
Community Health Representative II
Centene Corporation Burr Ridge Il
2019 to 3/2024
●Completes health assessments for DCFS Youth in Care to determine qualifications for case management based on acuity.
●Report specific health & social information to the case management team to asset in development of care plans.
●Coordinate services with community-based organizations. Produces and mails routine CM letters and program educational material.
●SME for Health Risk assessment completion and processes.
●Assisted with administrative tasks, including analyzing reports to monitor health engagement team metrics, quality, other functions as needed.
●Communicate with professionalism to physicians, office managers, providers, and other third parties to secure needed information.
●Initiate authorization requests for output or input services in keeping with the prior authorization list.
●Completes special assignments and projects instrumental to the function of the department.
●Verifies member insurance coverage and/or service/benefit eligibility via system tools
●Managing and analyzing daily reports using excel formulas to make sure data is accurate
HEDIS Clerk
Blue Cross Blue Shield Chicago Il
2019 to 2019
●Maintain Compliance with HIPAA and member confidentiality.
●Request medical records for comprehensive review.
●Met weekly with HEDIS coordinators to discuss HEDIS productivity and any opportunities.
●Evaluate quality of services from health care providers.
●Adherence to NCQA guidelines and technical specifications.
●Maintains compliance with HIPAA and patient confidentiality requirements.
Case Management Processer
Molina, Oakbrook Il
2016 to 2018
●Motivational interviewer: educate and support change during member contact, create FHP/ICP/MMP 3 goal care plan with DAR
●Promote integration of service for member including behavioral health care and long-term services and supports home and community.
●Assist with daily operations (billing, claims, enrollment, customer service, HEDIS metrics). Assist quality team with performance measure (HEDIS).
●Processes member and provider correspondence. Works with analytics team to ensure reporting, auditing, and analysis of healthcare services data.
●Works with manager to build and implement program policies.
●Adhered to productivity metrics and submits daily reporting to supervisors.
●New hire preceptor
●Completes Health assessments and determines qualifications for Case Management based on judgement, changes in member’s health, and listening to members concerns.
Program Coordinator
Illinicare Health Chicago Il
2015 to 2016
●Assists in preparing and submitting activity reports, evaluation plans, and reports data for further recommendations and issuance of disease control measures.
●Coordinates services with community-based organization.
●Researched claims inquired specific to the department and responsibility.
●Verifying demographics and aother duties as assigned.
●Data enter assessments and authorizations into the system.
●Screen for eligibility and benefits. Identify members without a PCP and refer to Member Services. Answers phone queues and faxes within established standards. Screen members by priority for CM assessment.
Program Coordinator
Maxim Health Chicago Il
2014 to 2015
●Appointment scheduling, verifying insurance and eligibility, calling for various reports.
●Patient interaction via phone and face to face.
●Assisting health plan members with transportation, resources for food, shelter, dental and vision.
●Providing care coordination to health plan members, ensuring member are medical compliant.
●Completing Health Screening Assessments to determine member’s needs.
●Provide benefit details.
●Produces and mail routine Case Management letters and program educational material.
●Coordinates services with community-based organization.
●Researched claims inquired specific to the department and responsibility.
●Verifying demographics and other duties as assigned.
Education
Medical Insurance Billing and Coding, Diploma
Everest College, Skokie Il
Skills
Billing and Coding Medicaid/Medicare/HMO SACWIS/MEDI OMNI
Excel/Word/PowerPoint
DCFS Trucare Claims
ICD9-CPT Coding
HFS Policies
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