Medical Manager

PAMELA PRADIA-MATTHEWS

**** ******** **. ******* ** 77072 · 917-***-**** adcxrp@r.postjobfree.com

Looking to secure a position as a Case Manager that will allow the use of outstanding conflict-management and interpersonal skills, as well as the utilization of critical thinking, service orientation, and social awareness to make a positive contribution to the organization.

EXPERIENCE

2006 – PRESENT

AUTHORIZATION COORDINATOR/ COMMUNITY AND STATE COORDINATOR, UNITED HEALTHCARE GROUP

Knowledge of medical terminology, referral and authorization practices, standard-coding methodologies (CPT, ICD-10, HCPCS).

Managed provider UM training and health fairs.

Responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities and ancillary providers.

The incumbent will be responsible for prior authorization and referral related processes that includes on-line responsibilities as well as selected off-line tasks.

Reviews assigned requests for medical appropriateness, verifies and processes for; specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment.

Completes required documentation for data entry into the utilization management system including any authorization updates.

Refers cases of possible over/under utilization to the Medical Director for proper reporting.

Manages the long-term care, Medicaid, and Medicare advantage process. 2001 – 2006

SENIOR HEALTHCARE COORDINATOR LEVEL I, UNITED HEALTHCARE GROUP

● Manages the efficient flow of information between patients, the medical staff and third-party requestors.

● Charge entry, registration, scheduling, insurance verification, pre-authorizations, and check in and check out functions to facilitate patient visit and ensure timely and accurate claims submission.

● Trains junior coordinators on processes, policies, and procedures.

● Assist the physician and medical staff in clinic, following necessary clinic protocols and medical regulatory standards.

● Identified issues and retention concerns represented by prospects or new members and alerts management on a timely basis.

● Assisted field Care Manager/Clinical staff with facilitating members healthcare needs. PAMELA PRADIA-MATTHEWS

EDUCATION

STUDIED SOCIOLOGY, UNIVERSITY OF HOUSTON

SKILLS

Windows XP and higher, Excel, Outlook window

word, Omega etc.

Milliman trained, Careone, RightFax, Lotus

Notes, Cosmos ICUE

Facets CSP, ICD-10, CPT and HCPC codes.

Medical terminology and standard coding

Long term care, Medicaid, Medicare advantage

Possess exceptional leadership, and

communication skills

Highly dedicated, organized, and

compassionate

Solid understanding of working with

patients from various illnesses

Ability to coordinate with different medical

personnel

ACCOMPLISHMENTS

Vital Signs Committee member, helping promote employee survey participation and action resolution for department upgrades.

Piloted the Medicare Advantage for the state of Texas STARPLUS member population.

Member of Employee Engagement Committee.

Facilitated focus groups on improvements for updates SOPs and department Share Point.

Analyst for Employee Engagement Committee to help foster departmental changes by bridging the communication gaps between staff members and management. Member of Autism Speaks

Jack and Jill of America

Volunteer with Upward Bound Trio Program

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