Utilization Management Concurrent Review Coordinator

BRITTANY R. GAYNOR

HOUSTON, TX *****

MOBILE: 832-***-**** OTHER: 832-***-****

E-MAIL: ********.********@*****.***

Education:

High School Diploma Gulf Shores Academy 2006

Summary of Skills:

●Effective strong verbal and written communication and organizational skills.

●Positive, helpful approach to problem solving.

●Ability to prioritize to meet deadlines.

●I also have HR Generalist experience.

●Administrative and clerical.

●Strong critical thinking, leadership and problem solving skills.

●Knowledgeable in CMS, Texas Medicaid, and other regulatory agency rules and regulations.

●Served as a preceptor and mentor to other staff.

Work Experience:

Community Health Choice

Utilization Management Concurrent Review Coordinator

Feb 2019 --

●Responsible for the quality and resource management of all Medicaid, CHIP, CHIP-P and Marketplace patients that are admitted to the facility from the point of their admission.

●Processed authorizations for inpatient admissions, therapy and skilled nursing request.

●Conducts concurrent reviews of all inpatient, partial hospitalization, medical records to ensure criteria for admission and continued stay are met and documented, and to ensure timely discharge planning.

●Consulted with the physicians and or hospital facilities whenever admission or continued stay does not meet approved criteria and cannot justify the admission or continuation of hospitalization.

●Obtained necessary clinical information from facility staff, practitioners and providers

●Used the clinical information provided by facility staff, practitioners and providers to determine benefits coverage.

●Clinical case appeals, discharge planning and disease management.

●Identified discharge planning needs at the beginning of the inpatient stay and reassessing these needs throughout the stay.

HSCS (Health Care Service Corporation)

Clinical Appeals and Grievance Coordinator

September 2018 -- December 2018

●Reviewed and processed pre-service and post-service clinical and non-clinical appeals previously denied by the (MRU) Medical Review Department.

●Administered ongoing appeal tracking, trending and reporting for assigned appeals.

●Processed appeal determination letters for written and verbal pre-service and post-service clinical or non-clinical authorization denials from members and providers.

●Conduct pertinent research to evaluate, answer, and close appeals.

●Ensure all HIPAA and State requirements/regulations are adhered to at all times.

Anthem

Medical Management Specialist I

February 2017 – June 2018

●Gathered clinical information regarding cases and determined area to refer or assign case (utilization management, case management, QI, Med review)

●Provided information regarding network provider’s general program information when requested.

●Acted as liaison between Medical Management and/or Operations and internal departments.

●Prepared reports and documented all actions.

●Processed Pre-service review (pre-certification, preauthorization, prospective review) for Medical and therapy services

●Insurance Verification, Concurrent review, Medical records.

●Post-service (retrospective) review.

●Case management, utilization management.

Aetna

Medicare Claims and Member Service Operations

September 2015 – October 2016

●Medicare claims, benefits Specialist. Followed CMS Medicare guidelines.

●Delivered Medicare Part D program health care services to members, providers, and plan sponsors also documented and tracked contacts with members, providers and plan sponsors.

●Explained member's rights and responsibilities in accordance with the contract. Determines medical necessity, applicable coverage provisions and verified member plan eligibility relating to incoming correspondence.

●Benefits and claims examination. Escalated appropriate referrals.

●Processed grievance and appeals and pre-authorizations and claims according to client requirements

●Educated participants, on self-service options;

●Assisted providers with credentialing and recredentialing issues.

General Dynamics Information Technology

Benefit Enrollment Specialist

September 2014 – June 2015

●Utilized scripts, standard operating procedures, and training materials in response to questions dealing with basic health care information.

●Processed enrollment for Obama Care through the Affordable Care Act.

●Provided knowledgeable responses to inquiries (phone, web chat, e-mail, TTY, fax, correspondence) in a courteous and professional manner.

●Adhered to Privacy Act and Health Insurance Portability & Accountability Act (HIPAA)

Mercer

HR Generalist

September 2011 – August 2013

●Delivered exceptional Human Resources services and solutions to the company through dedicated consultation within the HR team and our customers (Executives, Managers, and employees).

●Processed onboarding, day-to-day, and annual open enrollment benefits administration and education through HRIS management, employee relations, compensation and leave management.

●Actively worked within the HR team to ensure compliance with third-party vendors and processes.

●Preparing annual EEO1 reporting – establishing data audit practices within HRIS to insure clean data is ready at time of submission.

●Processed Employment Verifications, Managing the Unemployment Claim process HR compliance tasks (I9, E-Verify, FLSA, etc.)

UPS

Administrative Assistant

September 2010 – September 2011

●Performed various secretarial clerical duties such as documenting, photocopying, faxing, mailing, and organizing filing systems.

●Maintains files and calendars.

●Answered telephones and transferred calls to appropriate staff members.

●Sorted and distributed incoming communication data, including faxes, letters and emails.

●Processing Invoices, managing others schedules, time reporting, ordering office supplies.

●Interacted with organizational staff, executives, clients, vendors and visitors on a daily basis.

United Health Care

Customer Care Professional

August 2008 – April 2009

●Provided expertise and customer service support to members regarding Americhoice Medicaid plans, benefits and coverage details

●Answered incoming phone calls from health care providers (i.e. physician offices, clinics) and (EG. benefit and eligibility, billing and payments, authorizations for treatment, explanation of benefits)

●Medicaid and CHIP Children's Medicaid claims.

●Focused on resolving issues on the first call, navigating through complex computer systems to identify the status of the issue and provide appropriate response to the caller.

●Escalated issues, errors and trends to the Team Leader or Supervisor appropriately

●Processed claims, direct phone-based customer interaction to answer and resolve a wide variety of inquiries handles patients' questions, complaints, problems and concerns

●Explained policies and procedures to patients and refers them to the proper services required

Systems and Programs:

Advanced computer skills in Microsoft Office Suite including Microsoft Word Microsoft Excel Microsoft Outlook Microsoft PowerPoint Visio Jabber Skype Zoom WebX Citrix IDT Facets Macess Epic IDX Navigator Epic SAP HRIS Enterprise Appeals Application (EAA) SharePoint Oracle Dashboard JIVA QNXT PeopleSoft Cactus Kronos ADP NCQA

Skills:

(HIPAA) QUEST (Quality training) Call center Enrollment Customer service Member services Enrollment Claims Benefits Medicaid Medicare Provider Relations HEDIS Credentialing Case management Authorizations Managed Healthcare plans Calendar managing Grievance & Appeals Insurance verification Medical terminology URAC CPT ICD9 & ICD10 Coding and billing Discharge planning COB EOB

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