Pharmacy Utilization Review Coordinator with excellent data entry skills and telephone etiquette. Detail-oriented and focused on accuracy and efficiency.
Pharmacy Utilization Review Coordinator June 2012 to CurrentSedgwick Claims Management Services － Memphis, TN
Identifies treatment plan request(s) and obtains and analyzes medical records that support the request.
Identifies and enters CPT Codes along with ICD-9 & 10 codes Clarifies unclear treatment plan requests by contacting the requesting provider's office.
Communicates and works with claim examiners as needed to provide clinical information to resolve issues.
Accesses, triages and assigns cases for utilization review.
Responds to telephone inquiries proving accurate information and triage as necessary.
Enters demographics and Utilization Review information into claims or clinical management system; maintains data integrity.
Obtains all necessary information required for processing from internal and external sources per policies and procedures.
Distributes incoming and outgoing correspondence, faxes and mail; uploads review documents into paperless system as necessary.
Supports other units as needed.
Pulls and sorts medical records required for Medicare compliance referral from an appropriate sources; identifies missing documents/records; requests missing documentation from provider, examiner and/or defense counsel.
Analyzes and submits medical records to nurses to enable them to complete referral in a timely manner; uploads referrals and reports from claims system into Medicare Compliance System (MCS); ensures MCS is updated properly.
Documents records handler activity; communicates action with examiner Maintains a score of 90% or higher on monthly internal utilization review audits.
Entered new patient profiles and prescriptions into medication input software system.
Communicated directly with doctors' offices via telephone, fax and email.
Efficiently answered multi-line phone and processed high volume of order requests from nurses, doctors and pharmacists. Answered and screened phone calls for the staff pharmacist in a friendly, efficient manner.
Strictly maintained customer and patient confidentiality.
Communicated with all customers and staff in a pleasant and professional manner.
Precisely processed third party prescriptions and managed adjudication review.
Customer Service Representative November 2010 to June 2012Sedgwick Claims Management Services － Memphis, TN
Assists in evaluating the medical necessity, appropriateness and efficiency of the use of health care services as assigned.
Responds to requests for authorization for services utilizing appropriate guidelines.
Verifies injury and/or occupational disease process that prevents full return-to-work (RTW) status.
Reviews cases for remain-at-work and vocational rehabilitation services.
Assists with utilization management quality assurance initiatives through participation in on-line log and/or case staffing with supervisor.
Completes C-9s, vocational referrals and ER reviews within guidelines as assigned; documents all activities and communications in appropriate system(s).
Patient Account Representative April 2007 to June 2009Accredo Health Group － Memphis, TN
Kept accounting records and compiled information requested by customers and others handling customer accounts.
Maintained accounting records by making copies; filing documents Maintained database by entering data and processing backups Reconciled statements by comparing statements with general ledger Specialized in handling inquiries received by mail, compiling information from customer accounting records for replies dictated by others.
Transmitted claims for payment and further investigation.
Prepared and reviewed insurance-claim forms and related documents for completeness.
Provided customer service, such as giving limited instructions on how to proceed with claims and providing referrals to in network facilities.
Posted and attached information to claim file.
Reviewed insurance policy to determine coverage.
Calculated amount of claim.
Organized and worked with detailed records, using QuickBooks to enter, access, search and retrieve data.
Contacted insured and other involved persons to obtain missing information.
Protects organization's value by keeping information confidential.
Verifies financial reports by running performance analysis software program.
Updates job knowledge by participating in educational opportunities.
Claims Processor June 2006 to April 2007Third Party Solutions － Memphis, TN
Investigated claims against insurance for reimbursement for worker's compensation claims.
Examined claim form and other records to determine insurance coverage.
Interviewed, telephoned, and corresponded with claimant and witnesses.
Consulted employers, medical doctor's offices and hospital records.
Inspected property damage to determine extent of company's liability, varying method of investigation according to type of insurance.
Prepared report of findings and negotiated settlement with claimant.
Customer Service Representative February 2006 to June 2006SITEL － Memphis, TN
Checked to ensure that appropriate changes were made to resolve customers' problems.
Kept records of customer interactions and transactions, recording details of inquiries, complaints, and comments, as well as actions taken.
Contacted customers in order to respond to inquiries and to notify them of claim investigation results and any planned adjustments.
Referred unresolved customer grievances to designated departments for further investigation.
Medical Records Clerk January 2003 to January 2005The Regional Medical Center at Memphis － Memphis, TN
Reviewed records for completeness, accuracy and compliance with regulations.
Compiled and maintained patients' medical records to document condition and treatment and to provide data for research and cost control and care improvement efforts.
Entered data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer.
Released information to persons and agencies according to regulations.
Planned, developed, maintained and operated a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
Identified, compiled, abstracted and coded patient data, using standard classification systems.
responded to written and telephone requests for medical records and last visitation.
Education and Training
Bachelor of Science : Organization Leadership, 0517Bethel University － Memphis, TN, USABachelors of Organizational Leadership and Management
Professional and friendly, Careful and active listener, 10-Key, Computer Proficiency, Data Collection, Data Entry, Documentation, Email, Filing, Grammar, Internet Research, Spreadsheets, Telephone Skills,Type 50 WPM, Microsoft Excel, Microsoft Office Suite, Microsoft Outlook, Microsoft PowerPoint, Microsoft Word, Organizational Skills, Prioritization
Excellent oral and written communication, including presentation skills