Home Care Utilization Review

Melissa Crawford

Brooksville, FL ᐧ *********@*****.*** ᐧ 727-***-****

EXPERIENCE

Care Centrix

Coordinator Appeals and Peer to Peer

September 2022 - Present

●Manage incoming and outbound calls to support the appeals and peer to peer process

●Maintains high quality of data and documentation

●Process and document health determinations for appeal requests

●Ensure timely responses to health plan partners so appeals may be processed according to regulatory times

Utilization Review

February 2018 - September 2022

●Reviewed accounts for missing information

●Assess appropriateness and necessity for homecare

●Ensure patients receive appropriate level of home care

●Use analytics platform to review patient data for areas of optimization

Network Service Team

May 2016 - February 2018

●Ensure right providers are available to patients based on their needs

●Coordinate care delivery within network

●Serve as a bridge between patients, their care plans, and home care

●Monitor quality metrics and patient satisfaction

Provider Staffing

December 2011 - May 2016

●Review patient referrals to assess needs

●Streamlined assignment of patients to providers within network to ensure accurate and timely placement

●Ensure the provider matched is appropriate for patient specific needs

Westchase Primary Care, — Medical Billing/Referrals

January 2011 - December 2011

●Insurance verification and demographic entry

●Payment handling

●Charge entries

●Worked/secured referrals for office visits

●Worked aged accounts with discrepancies for completion

SKILLS

Microsoft Office/Word/Excel

HCPCS

Medical Coding

Customer Service

Conflict Resolution

EDUCATION

FL Career College-Health Insurance Billing and Coding

January 2010-October 2010

Career Institute of Florida-Medical Assistant

August 2007- June 2008

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