Case management and Prior Authorization Professional

Tori Wiley

Pasadena, MD 443-***-**** ********@*****.***

Case Management Healthcare Client Services

Professional Summary

Versatile professional with extensive experience in human services case management, healthcare administration, and medical management support. Skilled in benefit verification, prior authorization coordination, and insurance documentation for medical procedures, skilled nursing facilities, and home infusion therapies. Experienced supporting both clinical and non-clinical teams through intake, utilization review support, and care coordination, while tracking status and ensuring timely follow-up. Working knowledge of ICD-10, HCPCS, and CMS guidelines, with proven ability to interpret coverage, confirm eligibility, and communicate next steps to members, providers, and internal teams. Known for maintaining accurate documentation across multiple systems, protecting PHI under HIPAA, and delivering clear, empathetic communication to drive safe, compliant, patient-centered outcomes.

Core Strengths

Case Management • Benefit Verification • Prior Authorization • Medical Management Coordination •

Utilization Review Support • Insurance Documentation • ICD-10 & HCPCS Coding • CMS Guideline Knowledge • Client & Provider Communication • Eligibility & Coverage Assessment • Data Accuracy & Compliance • HIPAA Confidentiality • Microsoft Office & Google Workspace

Technical Proficiencies

Microsoft Office Suite (Word, Excel, Outlook, Teams) • Google Workspace (Docs, Sheets, Gmail) • EMR & CRM Systems • Case Management Portals • Authorization/Benefits Platforms • HIPAA & CMS Compliance Tools

Professional Experience

Family Investment Specialist II (Case Manager)

Maryland Department of Human Services / Baltimore City Department of Social Services – Baltimore, MD Mar 2023 – Present

•Manage an active caseload, conducting phone and in-person interviews to assess needs, determine eligibility for medical, nutritional, and social service programs, and coordinate next steps.

•Review and verify financial, insurance, and supporting documentation for accuracy, completeness, and compliance with state, federal, and CMS guidelines.

•Coordinate care and connect clients with appropriate medical, behavioral health, pharmacy, and community resources; communicate outcomes and requirements clearly to members.

•Document all case activity in multiple systems, track status, and ensure timely follow-up, escalation, or referral when needed to avoid service gaps.

•Use Microsoft Office and Google Workspace to maintain case notes, generate reports, and track deadlines with a high level of accuracy and confidentiality.

Inbound/Outbound Queue Associate (Medical Precertification)

Aetna, a CVS Health Company – Remote Nov 2022 – Mar 2023

•Processed and tracked prior authorization requests for medical procedures, skilled nursing facility stays, and home infusion therapies, ensuring requests met medical necessity and policy requirements. • Verified member eligibility and benefits across multiple systems and explained coverage details and next steps to providers and members in clear, patient-friendly terms.

•Applied ICD-10 and HCPCS coding information to clinical documentation to support authorization review and medical appropriateness.

•Maintained detailed records of all contacts and status updates to support utilization review activity, escalation, and compliance with HIPAA and CMS standards.

Associate Consultant – Services

Progressive Casualty Insurance Co. – Remote Apr 2022 – Nov 2022

•Reviewed, documented, and clarified complex insurance coverage and benefit questions with accuracy and confidentiality.

•Coordinated with internal teams to resolve policy discrepancies, research eligibility details, and ensure timely response to members.

•Delivered service using active listening, clear communication, and high attention to detail in a fast-paced, metrics-driven environment.

Intake Coordinator

Versant Health – Remote Oct 2019 – Apr 2022

•Processed prior authorization requests and completed benefits verification for medical and vision services in alignment with NCQA and CMS standards.

•Confirmed eligibility, gathered required clinical documentation, and tracked status to support timely approval and scheduling of services.

•Maintained audit-ready documentation in EMR/CRM systems and ensured PHI confidentiality underHIPAA.

•Communicated with providers, members, and internal teams to resolve missing information, clarify requirements, and prevent delays in care.

Team Lead / Certified Medical Assistant

Johns Hopkins Regional Physicians DBA ENTAA Care – Glen Burnie, MD Nov 2016 – Jun 2019 • Coordinated clinic operations for a high-volume ENT and Allergy practice, supporting multiple providers and clinical staff.

•Submitted, tracked, and followed up on prior authorizations for imaging, medications, and procedures

•Verified insurance benefits and clarified coverage limitations to patients.

•Used ICD-10 and HCPCS codes to support authorization and billing requirements and to ensure documentation accuracy in the EMR.

•Scheduled patients, prepared clinical documentation, and ensured readiness of chart and medical history for provider review.

•Trained and supported clinical staff on documentation standards, patient communication expectations, and insurance-related workflows.

Certified Medical Assistant / Satellite Office Lead

Physical Medicine & Pain Management Associates – Annapolis, MD Jan 2013 – Nov 2016 • Supported physicians across multiple locations, assisting with direct patient care, clinical documentation, and coordination of services.

•Processed prior authorization requests for procedures, diagnostic imaging, pain management treatments, and therapies; verified benefits and gathered required documentation from payers.

•Applied ICD-10 and HCPCS coding information to ensure accurate and complete authorization submissions and reduce delays.

•Maintained HIPAA and CMS compliance while preparing patient charts, communicating with pharmacies and schedulers, and documenting required follow-up.

Education & Certifications

Certificate in Clinical Medical Assisting – Anne Arundel Community College, Arnold, MD

Certified Medical Assistant (Inactive) – American Association of Medical Assistants

BLS for Healthcare Providers – American Heart Association

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