Case Manager Data Entry
Resume:
Alma Rosa Correa
Canoga Park, CA. 91304
**********@***.***
Highlight of Qualifications:
Renal/ESRD End Stage Renal Disease experience in assisting Case Managers avoid E.R admit and smoothly transition our members into outpatient Hemodialysis.
SNP/CMC Program Coordinator/Vital Care Coordinator-8 years of experience.
In depth understanding of SNP/CMC process.
Extensive experience in Managed Care and Medical Management.
Outpatient Utilization Management experience in meeting referral turnaround times, high volume of data entry, benefit and eligibility verification. DOFR-Division of responsibility, carve out letter process, In depth understanding of referral networks and utilization of assigned providers to networks. Work Experience
Renal Coordinator
Regal Medical Group June 2016- Present
Northridge, CA, United States
Work closely with Outpatient Case Managers, Medical Director, Program Director, Nephrologists, Vascular Surgeons, and Dialysis Centers to optimize member’s plan of care.
Track renal related admissions for annual outcome summary.
Reconcile CKD and ESRD monthly reports for renal outcomes.
Responsible for maintaining and updating Excel spreadsheet for tracking and identifying renal program goals.
Assist with timely referrals to nephrologists and vascular surgeon’s offices.
Provide Renal Team and Program Director with monthly outcomes.
Daily Renal / ESRD admissions data research for clinical review of Renal /Non-Renal related preventable admissions.
SNP/CMC Coordinator Jan 2014 – June 2016
Regal Medical Group
Inform the Case Manager of current annual assessments in compliance with health plan guidelines.
Case Preparation for Case Manager to review.
Obtaining all medical records from multiple systems including Next Gen, QHMO, REA/LEA, specialist and PCP offices and upload them to the system.
Eligibility and benefit verification.
Entering all referrals / orders as needed per Case Manager.
Responsible for maintaining and updating Microsoft Excel spread sheet with most current annual reviews due.
Taking and filing of all ICT meeting minutes.
Work closely with Case Manager to make sure all cases meet health plan guidelines. Vital Care Coordinator May 2008 – Jan 2014
Regal Medical Group
Work closely with Vital Care Nurse, Medical Director, PCP and other team members to optimize member’s plan of care.
Facilitate appointments for the member to PCP, specialists or diagnostic studies.
Arrange transportation as needed.
Assist member with any PCP or specialist issues.
Assist and provide member with educational materials pertaining to Urgent Care, Hospice, flu clinics and diet.
Process Vital Care referrals.
Obtaining all medical records for Case Manager to review.
Eligibility and benefit verification.
Assisting providers and office staff with prior authorization. Out Patient Utilization Management Coordinator March 2003 - May 2008 Regal Medical Group
Anticipate our customer needs: Understand the wants and needs of customers, listen for cues and identify how to respond and what level of intervention they need
Understand and execute the principles of UM to facilitate the right care at the right time in the right setting.
Communicate effectively and interact with the provider group and health plans daily or as indicated regarding UM and referral authorization issues.
Data entry
Process request that are approved, denied or deferred and bring them to resolution.
Responsible for Deferred authorization maintenance, tracking and follow up.
Responsible for the EIOD process, including log maintenance; and patient notifications
Checks eligibility and benefits on all DME and home health authorizations prior to forwarding on request to prior authorization nurse or medical director for approval.
Front office, eligibility, and authorization verification. Charting, filing, patient check in, copay collection, appointment scheduling.
Education
Bryman College Reseda, CA, United States
Medical Assistant-Mar 1996 - Mar 1997
Skills
Microsoft Word
Microsoft Excel
Data Entry
Communication
References available upon request.
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