Melanie Payne

About Melanie Payne

Consultant, over 20 years Immediately I\'m seeking an…

Experience

1. Healthcare Consultant

   Advance Care Solutions, Llc

   Nov 2015 — Present · US

   Receives phone calls and faxed referral requests from providers. • Scheduling Coordinator.• Verifies member eligibility and benefits. • Inputs all referral requests including ICD-10 and CPT codes into system accurately for electronically generated authorization tracking. • Provides referral authorization to external providers per UM Departmental Policy and Procedures and specific contracted Client\'s process. • Requests submission of appropriate medical records according to established criteria for requested service(s). • Issues authorization within appropriate timeframe for routine, urgent and emergent requests. • Appropriately forwards all referral requests to the next level of review. • Coordinates approved outpatient surgical procedures in specialist\'s office and/or outpatient surgical facilities with health plan\'s authorization department when applicable. • Coordinates approved services with Home Health Providers, Plan discharge Planners and Plan Members as delegated or required by Plan. • Is resource person for PCP to refer to network specialist(s).• Compiles monthly departmental statistics. • Distributes correspondence and other information to the appropriate parties or departments. • Maintains appropriate logs, records, and reports as established by Utilization Department. • Identifies providers who are problematic with plan requirements.• Ensures that referrals are addressed in a timely manner. • Keeps denial log, on a monthly basis. • Follows up on pending orders on a daily basis. • Ensures that all HIPAA/ OSHA standards are in compliance.• Experience with a health plan/health insurer and/or Medicare/Medicaid.

Skills

• Visio
• Software Documentation
• Requirements Gathering
• Sdlc
• Business Analysis
• Project Management
• Business Process Improvement
• Requirements Analysis
• Process Improvement
• Healthcare
• Data Analysis
• Business Intelligence
• Program Management
• Healthcare Information Technology
• Change Management
• Customer Service
• Provider Enrollment
• Eligibility
• Benefits Administration
• Insurance Adjusting
• Credentialing
• Appeals
• Auditing
• Technical Recruiting
• Internet Recruiting
• Contract Recruitment
• Talent Acquisition
• Management
• Applicant Tracking Systems
• Business Strategy
• Business Development