Ealer S. Wadlington
Utilization Management Representative Ii @Elevance Health
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WORK HISTORY
Utilization Management Representative Ii @Elevance Health
Managing incoming calls or incoming post services claims work. Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests. Obtains intake (demographic) information from caller. Refers cases requiring clinical review to a Nurse reviewer.How my role makes an impact:• Manage incoming calls or post services claims work• Provide authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests• Refer cases requiring clinical review to a Nurse reviewer• Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate• Respond to telephone and written inquiries from clients, providers, and in-house departments• Conduct clinical screening process• Authorize initial set of sessions to provider• Checks benefits for facility-based treatment• Develop and maintain positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.• Obtain intake (demographic) information from caller• Conduct a thorough radius search in Provider Finder and follow up with provider on referrals given• Refers cases requiring clinical review to a nurse reviewer, handle referrals for specialty care• Process incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for precertification and/or prior authorization• Responsible for providing technical guidance to UM Reps who handle correspondence and assist callers with issues concerning contract and benefit eligibility for requested continuing pre-certification and prior authorization of inpatient and outpatient services outside of initial authorized set• Handling escalated and unresolved calls from less experienced team members
EDUCATION
Hondros College of Business
Insurance - Pre-licensing Certificate, Life, Accident, Health and Annuities
Xavier University
Bachelor of Arts (BA), Communications, Electronic Media concentration
ABOUT EALER S. WADLINGTON
Professional that adapts to last minute, urgent changes and by multitasking, applying foresight to anticipate situations and events, and maintaining accuracy under pressure. A recognized thoughtful leader and creative thinker with ability to build relationships and work with cross-functional teams. I am a very creative writer who has worked across multiple marketing mediums and campaigns such as print, radio, SMC emails, videos, social media posts, events, landing pages, and websites. I have recent proficiency using Outlook, MS Teams, Microsoft Excel, Microsoft Office, Microsoft Project, Microsoft Word, PowerPoint, and various other software programs. I have a great deal of experience working collaboratively with other creatives such as graphic designers, UX/UI designers, and digital developers. Also, I can communicate with customers, members or providers, as well as, other audiences as a company’s primary audience. Areas of expertise include: Online & Print Media • Radio & Print Reporting • Associated Press Stylebook • Photo / Graphic Selection • Public Speaking / Presentation • Washington Post Stylebook • Interpersonal Relations • Special Projects • Research • Pagination Systems • Breaking News Reporting • Keeping the Writer’s Tone • Dissemination of Information • Life Insurance • Accident / Health Insurance • Customer Service • Sales
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