utilization management specialist resume example with 7+ years of experience
JessicaClaire
Public Relations Specialist
, , 609 Johnson Ave., 49204, Tulsa, OK100 Montgomery St. 10th Floor
Home: (555) 432-1000
Cell:
resumesample@example.com
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Professional Summary
Reliable individual bringing 8 years of experience in healthcare environments. Maintains positive relationships with case managers and providers. Remains polished and calm under extreme stress. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills within the world of marketing and public relations.
Skills
Customer Experience
Medical Recordkeeping
Payment Processing
Obtaining Authorizations
Determine Medical Necessity
Invoice Statements
InterQual Criteria
Office Support
Creative Thinking
Insurance Eligibility
Microsoft Excel, Microsoft Word, Microsoft PowerPoint
Utilization Review
Work History
Utilization Management Specialist, 10/2019 to Current Allina Health Systems – Golden Valley, MN,
Provide excellent service to providers and members.
Evaluate outpatient service request in adherence to medical guidelines from clinical based resources and benefit coverage to determine appropriateness of services.
Document all incoming and outgoing interactions.
Ensure the protection of member and provider information and/or medical documentation.
Adhere to company policies.
Perform prior authorization review of services requiring notification.
Submit cases to Medical Director for criteria failures and helped facilitate resolutions and determinations.
Devise or identify solutions for irregular requests and issues.
Discussed medical histories with patients in effort to provide most effective medical advice.
Defined testing protocols, quality assurance initiatives and clinic policies and procedures.
Member and Provider Services Representative, 03/2018 to 10/2019 Nursecore – North Port, FL,
Delivered exceptional customer service to every member and provider by leveraging extensive knowledge of benefits and services and creating welcoming, positive experiences.
Documented all incoming and outgoing interactions
Exhibited high energy and professionalism when dealing with clients and staff.
Investigated and resolved member and provider inquires during call, or within a timely manner if it required further review
Delivered prompt service to prioritize customer needs.
Met customer call guidelines for service levels, handle time and productivity.
Responded proactively and positively to rapid change.
Educated customers about billing, payment processing and support policies and procedures.
Responded to customer requests, offering excellent support and tailored recommendations to address needs.
Promoted superior experience by addressing customer concerns, demonstrating empathy and resolving problems swiftly.
Maintained up-to-date knowledge of product and service changes.
Trained new personnel regarding company operations, policies and services.
Sought ways to improve processes and services provided.
Ensured the protection of member and provider information and/or medical documentation
Adhered to company policies.
Medical Billing and Collections Specialist, 12/2014 to 03/2018 Cvikota Company – City, STATE,
Provided excellent customer service to patients and insurance representatives
Researched and resolved patient inquires in a timely manner, as well as documented all incoming and outgoing patient interactions
Ensured protection of patient information and medical records
Reviewed patient records, evaluated and cross referenced with insurance medical necessity criteria to predetermine validity of request prior to authorization submission
Responsible for resolving issues regarding approvals and denials of authorizations
Compiled and tracked outstanding balances owed to medical facilities.
Processed billing calls and answered questions from patients and third-party carriers.
Corrected, completed and processed claims for multiple payer codes.
Assisted in reconciling deposit and patient collections.
Processed online and paper appeal submissions and refund requests.
Handled account payments and provided information regarding outstanding balances.
Responded to customer concerns and questions on daily basis.
Monitored outstanding invoices and performed collections duties.
Executed billing tasks and recorded information in company databases.
Used data entry skills to accurately document and input statements.
Processed payment via telephone and in person with focus on accuracy and efficiency.
Produced and mailed monthly statements to customers and assisted with related requests for information and clarification.
Developed rapport with clients and vendors to cultivate loyalty and satisfaction.
Disbursed petty cash by recording entries and verifying documentation.
Received and sorted mail, prepared packages for delivery and scanned documents.
Trained and mentored new team members and managers on accounts payable systems and policies to build cohesive groups and promote operational performance.
Kept vendor files accurate and up-to-date to expedite payment processing.
Utilized talents and expertise to complete on-time and accurate monthly closing processes, journal entries and accruals.
Education
Bachelor of Science: Marketing Management, Expected in 05/2022 to Western Governors University - Salt Lake City, UT, GPA:
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