Licensed Clinical Reviewer Resume Example Amerigroup Corporation

LICENSED CLINICAL REVIEWER

Professional Summary

Hardworking [Job Title] bringing [Number] years of experience meeting customer needs via telecommuting roles. Skilled at listening to customers, meeting productivity targets and maintaining current knowledge of company offerings. Offering empathy, reliability and enthusiasm for satisfying customers. Experienced [Type] Insurance Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering [Number] years of experience and willingness to take on any challenge. Gifted in working with stressed, confused and upset individuals in need of benefits information and supportive guidance to navigate [Type] systems. Effective at operating within [Type] regulations and [Type] department guidelines to manage telephone calls, emails, letters and in-person requests for assistance.

Accomplishments

Managed a caseload of between [Number] and [Number] individuals and families.

Skills

Flexible & Adaptable
Computer skills
Verbal and written communication
Interpersonal Communication
Insurance Verification
Medicare and Medicaid knowledge
File and records management
ICD-10 Coding
Customer service and assistance
Problem-solving

Claims
Understanding of medical terms
Collaborative relationships
Prior authorization processing
Insurance coverage verification
Health insurance industry knowledge
Medical terms and procedure knowledge
Multitasking abilities
MS Office

Work History

Licensed Clinical Reviewer, 05/2012 to Current
Amerigroup Corporation – Nashville, TN

Received, recorded and addressed incoming and outgoing communication via telephone a
Reduced care costs without sacrificing quality through effective service coordination and multidisciplinary collaboration.
Addressed disruptions in patient care, including delays in discharge, postponed procedures and discharge equipment unavailability.
Helped patients receive appropriate, high-quality care with reasonable results.
Managed and streamlined referral queues of up to 25 by efficiently prioritizing patients and clearing insurance obstacles.
Performed prior authorization review of services requiring notification.
Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
Submitted cases to Medical Director for criteria failures and helped facilitate resolutions and approvals.
Performed admission reviews based for medical necessity based upon [Type] specification.
Tracked all pending authorizations to resolve discrepancies and avoid revenue loss.
Communicated effectively with staff, including members of operations, finance and clinical departments.

Medical Management Specialist, 06/2007 to 05/2021
Amerigroup Corporation – Nashville, TN

Interacted and communicated easily with department personnel and public.
Communicated effectively with staff, patients and insurance companies by email and telephone.
Used critical thinking to break down problems, evaluate solutions and make decisions.
Handled over 100 calls per day to address customer inquiries and concerns.

Foster Care Case Manager, 06/2006 to 06/2007
Family And Children's Services – Nashville, TN

Checked with newly placed children frequently to support comprehensive success and assimilation.
Created and updated systems of organization for case service plans and court reports.
Visited homes of families and maintained appropriate contact as directed by agency procedures.
Collaborated with community program leaders and advocates to make resources accessible to those in need.
Documented data and completed accurate updates to case records.
Built solid and trusting rapport with children and families, fostering trust and communication to meet case needs.
Completed home welfare checks to align with state and program guidelines.
Interviewed individuals and families to assess needs and provide informational resources.
Managed heavy caseload of [Type] and [Type] cases effectively through well-developed time management, organizational and task prioritization skills.

Foster Care Social Worker, 09/2002 to 06/2006
Department Of Children's Services – Nashville, TN

Assisted families in developing problem-solving and coping skills by providing counseling and referring to appropriate community agencies.
Conducted home, school and community visits to assigned clients to assess client's level of care and provide guidance towards meeting treatment goals.
Collaborated with case managers and community partners to deliver effective treatment and case collaboration.
Provided on-going support to resource parents through coaching and crisis intervention techniques.
Provided transportation for children and parents to and from visits and court.
Completed home welfare checks to align with state and program guidelines.
Documented data and completed accurate updates to case records.
Developed rapport to create safe and trusting environment for care.
Interviewed individuals and families to assess needs and provide informational resources.
Reported child abuse in accordance with legal standards of mandatory reporters.
Checked with newly placed children frequently to support comprehensive success and assimilation.
Attended proceedings and testified for several reunification and permanent placement cases.
Completed 3 monthly visitations to check on children, families and home environments.
Established parental eligibility through frequent meetings and reviewing information.
Referred families to shelters, legal resources and educational programs.

Education

Bachelor of Arts: Social Work, 05/2002
The University Of Tennessee - Martin - Martin, TN

Certifications

BSW License - 2012-preset

Resume Overview

Companies Worked For:

Amerigroup Corporation
Family And Children's Services
Department Of Children's Services

School Attended

The University Of Tennessee - Martin

Job Titles Held:

Licensed Clinical Reviewer
Medical Management Specialist
Foster Care Case Manager
Foster Care Social Worker

Degrees

Bachelor of Arts : Social Work , 05/2002

Licensed Clinical Reviewer Resume Example

Resume Score: 80%

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