Clinical Administrative Coordinator Resume Samples

Description :

1. Providing holistic family support to families of children with special needs, owning an end-to-end resolution of benefit issues.
2. Serving as an ongoing, single point of contact for members, primarily via the phone channel, delivering compassionate support to consumers, creating a memorable, positive consumer experience.
3. Creating and building ongoing relationships with others (to include both consumers and teammates).
4. Making decisions independently and solving problems creatively without requiring established procedures, using sound judgment and critical thinking, while consistently following through on commitments and framing realistic expectations for consumers.
5. Planning, prioritizing, organizing and completing the work to meet established objectives.
6. Anticipating the member needs and proactively seeking out external and internal resources where appropriate to add unexpected value for the member.
7. Demonstrating the ability to determine appropriate referrals to other programs/services as needed without technology guidance.

Experience

2-5 Years

Level

Junior

Education

BS

Description :

1. Responsible for intaking all new referrals, and the data input for both the new patient and the MD, hospital, or doctors office associated with the referral sent.
2. Responsible for making all welcome calls (onboarding process and financial discussion) to new patients, as well as keeping closely in contact with the Nurse Practitioners, Case Managers, and social workers to make sure the patient transition to home infusion setting is coordinated with care and fluidity.
3. Responsible for keeping in touch with our acute care specialist (sales reps) to make sure their referrals (from MD office hospitals) are being processed in a timely fashion as well as letting them know what information or piece are missing.
4. Keeping up to date with current insurance contracts, to keep up to date with reimbursement as well as quoting our patients pricing correctly.
5. Checking limitations of patients insurance policies in terms of deductible and out of pocket information, and what requires insurance authorizations prior to starting.
6. Responsible for giving updates to pharmacy and nursing departments throughout the day on the new patient start of care as well as updates on existing or hospitalized.
7. Helped the members with medical, behavioral and pharmacy needs as well as connect them with resources in and outside of the company.

Experience

2-5 Years

Level

Entry Level

Education

College

Description :

1. Working with the junior level staff to ensure metrics are met and provide assistance to nurses and management with case management needs.
2. Performing as an SME (Subject Matter Expert) in bilingual translation and updates of state insurance plan grids and contracts.
3. Experience with medical, dental, pharmacy insurance billing, adjudication and compliance.
4. Resolving customer service inquiries which could include: entering notifications and providers status of an existing inquiry, and determining if follow-up is required, and spanish language line assistance.
5. Providing superior bilingual customer service and administrative support to both providers and state audit members.
6. Constantly meeting and exceeding the established productivity, schedule adherence, and quality standards while maintaining good attendance and compliance.
7. Assisting the team with faxes and emails or questions from spanish speaking members.
8. Case management assistance for members of different cultures and diversities.

Experience

7-10 Years

Level

Senior

Education

College

Description :

1. Assisting clients with registration, scheduling, and insurance verification.
2. Meeting divisional productivity standards as outlined in the clinical review division.
3. Participating on a monthly focus group with the clinical director of UHC.
4. Collaborating with the team to address concerns and developmental progress for the CCR department.
5. Providing support services to nursing staff and clinical treatment teams.
6. Confirming the admit and discharge dates with facilities and physician offices.
7. Confirming the schedule surgeries for patients by calling physician offices. Medical coding and coverage determination necessary for claim processing.
8. Referring the patients to different disease management programs upon discharge from the hospital. Following hospice cases on a weekly basis.
9. Utilizing online tools to research physician data as well as in-house databases to research eligibility and in/out network status of providers.

Experience

10+ Years

Level

Consultant

Education

College

Description :

1. Managing administration for seventeen health centers throughout New York City.
2. Overseeing the daily operational clinic procedures (i.e., budget, purchase orders, data collection, schedule management clinic staff supervision and training, etc.).
3. Coordinating the monthly orientations of all clinicians to ensure compliance with federal, state, and agency policies.
4. Managing the internal and external reports, such as policy statements, grant proposals, and documentation.
5. Assisting with the medical team's satisfaction surveys for medical staff and patients, resulting in improved team member communication, and improved workflow.
6. Responsible for infection control coordinator ensuring doh compliance to infection prevention practices in collaboration with the clinic administrator resulting in the implementation of new infection prevention policies that reduced the spread of infection compared to last year.
7. Maintaining PCMH standards and policies within the clinics by planning staff meetings and preparing required documentation to remain in compliance.

Experience

7-10 Years

Level

Senior

Education

BS

Description :

1. Training new staff members/supervisors and constructing a job training aide for the primary state that I am responsible for.
2. Constantly meeting the established productivity, schedule adherence, and quality standards while maintaining good attendance.
3. Drafting of NOA/NOE letters for government and commercial specific clients for all the states in the department.
4. Responsible for ensuring the letter documentation meets client, regulatory and accreditation requirements.
5. Knowledge of the state and federal regulations concerning the services and benefits.
6. Demonstrating the understanding of the program by selecting the correct letter template.
7. Reviewing and processing the prior authorization requests to meet departmental key indicator productivity and accuracy standards, maintaining a minimum of 95% case data entry accuracy.
8. Following departmental policy regarding accurate documentation of clinical data, demographics and product information, provider/facility contract status, appropriate case routing, and appropriate non-clinical level notifications.

Experience

2-5 Years

Level

Junior

Education

College

Description :

1. Provided expertise claims support by reviewing, researching, and investigating all types of preventive and clinical claims to ensure members received appropriate critical measures.
2. Provided superior customer service for incoming and outgoing telephone calls to or from members, providers, employer groups and other persons deemed necessary by management.
3. Conducted telephonic, mail and in-person outreach to members, providers and community organizations to support utilization management, case management and/or quality improvement regulatory contractual metrics and requirements.
4. Educated members about preventative healthcare and schedule them for programs available to them through their individual health care plans.
5. Achieved performance metrics for production, quality assurance, and adherence goals, on a daily basis, showing consistency and often making top performer and high-quality assurance.
6. Provided telephone follow-up to ensure members have seen their PCP and are completing their treatment plan or preventive care services as defined by the PCP or guidelines.
7. Provided follow-up and resolution in response to the member intervention forms received from the PCP.

Experience

2-5 Years

Level

Junior

Education

BS

Description :

1. Proven track record of conceptualizing, building and executing team utilized excel computer databases.
2. Supervised other clerical staff and provide training and orientation to new staff.
3. Established work procedures or schedules and keep track of the daily work of clerical staff.
4. Provided services to customers, such as order placement or account information.
5. Conducted searches to find needed information, using such sources as the internet.
6. Learned to operate new office technologies as they are developed and implemented.
7. Composed, typed, and distributed meeting notes, routine correspondence, and reports.
8. Reviewed the work performed by others to check for correct spelling and grammar, ensuring that company format policies are maintained.
9. Operated office equipment such as fax machines, copiers, and phone systems, and use computers for spreadsheet, word.
10. Answered telephones and gave information to callers, take messages, or transfer calls to appropriate individuals.

Experience

7-10 Years

Level

Senior

Education

BA

Description :

1. Managing the administrative intake of members or the admission/discharge information post notification.
2. Working with hospitals, clinics, facilities and the clinical team to manage request for services from members and/or providers.
3. Managing the referrals process, processing incoming and outgoing referrals, and prior authorizations.
4. Receiving care coordination notification cases for non-clinical assessment/intervention.
5. Reviewing the requests for adverse determination, approval notification, and processing notification requirements.
6. Assisting the clinical staff with setting up documents/triage cases for clinical coverage review.
7. Handling resolution/inquiries from members and/or providers.
8. Assisting with obtaining any info/documents for the insurance verification process.
9. Providing all necessary info/documentation for the home care site for SOC.

Experience

2-5 Years

Level

Entry Level

Education

BS

Description :

1. Reviewing and process prior authorization requests to meet departmental key indicator of productivity and accuracy standards, maintaining a minimum of 95% case data entry accuracy.
2. Following departmental policy regarding accurate documentation of clinical data, demographics and product information, provider/facility contract status, appropriate case routing, and appropriate non-clinical level notifications.
3. Processing adverse determinations, consistently exceeding or meet compliance and business unit requirements (meaningful denial text, timely notification, and thorough documentation).
4. Processing UM-related pended claims, monitoring for trends related to the cause of pended claims, educating the co-workers on data-entry errors that cause pended claims, maintaining the age of UM claims less than 10 days.
5. Reviewing and processing actions grams from issue resolution specialists; research problem cases/claims and update facets accordingly.
6. Maintaining 100% accuracy and timeliness of letter generation. Providing a high level of customer service while communicating with internal departments and external provider office staff as pertains to the performance of job duties.

Experience

5-7 Years

Level

Executive

Education

High School