KATHRYN TUCKER

• Assessed and modified outgoing medical determination reviews, maintaining alignment with established company standards and ensuring quality control.
• Assessed and improved written materials for clarity, tone, and overall quality to support effective messaging.
• Developed and upheld systems for organizing and maintaining essential communications.
• Reviewed and refined content of medical reviews through meticulous editing, proofreading, and fact-checking to guarantee factual accuracy and adherence to compliance guidelines.
• Oversaw documentation of compliance and turnaround time (TAT) metrics for all correspondence notifications.
• Developed and upheld comprehensive correspondence protocols to ensure clarity and accuracy in provider and member communications for pre-service and concurrent reviews.
• Implemented and enforced policies and standards to uphold quality and regulatory requirements.

40+ hours a week

• Performed intake of calls from providers regarding denied services
• Screened requests for appropriate referrals to medical services staff
• Scheduled Peer-to-Peer reviews with medical directors as necessary
• Sent updated correspondence depending on peer-to-peer outcomes
• Approved services that did not require a medical review in accordance with the benefit plan

40 hrs/ week

• Managed and processed incoming intake requests through direct phone and fax interactions.
• Coordinated processing of prior authorizations and served as a liaison to enhance collaboration between healthcare providers and health plans.
• Drafted and submitted authorization requests for inpatient and outpatient procedures, streamlining patient care operations.
• Analyzed and confirmed eligibility benefits and prior authorization requirements to support accurate claims processing.
• Coordinated referral processes to ensure timely patient access to healthcare services.
• Developed and maintained relationships with providers to improve referral networks.
• Collaborated with healthcare providers to ensure accurate and complete referral information, improving patient care coordination.

40 hrs/ week

• Facilitated effective communication by managing high volumes of inquiries and requests from members and providers across multiple platforms.
• Conducted thorough screenings of referral requests to match them with appropriate medical services staff capabilities.
• Conducted outbound outreach to providers, ensuring collection of essential clinical information to support medical authorization decisions.
• Conducted comprehensive non-medical research to verify client eligibility and benefits.

40+ hrs/ week

• Promoted communication, both internally and externally to enhance effectiveness of medical management services for health care providers, and health care team members respectively
• Provided floor support; assisting staff with complex issues; research
• Collaborated with peers and department leaders; provided insight and observations to improve department operations
• Protected the confidentiality of member information and adheres to company policies regarding confidentiality and moral conduct
• Effectively performed administrative tasks for 35+ employees and management team
• Coordinated service delivery including attention to customers, understanding to issues, proactive identification and resolution of issues to promote positive outcomes
• Created, updated and modified new and existing job aids to ensure accuracy
• 40+ hrs/ week