Mary Jade Vergara

Provide documentation coverage for assigned healthcare providers, which involves listening to audio records of patient clinic visits/encounters using AI technology and support tools to summarize medical facts, findings and prescribed treatment plan into a professional clinical report/provider note format. Clinical reports/provider notes include but are not limited to history of present illness, physical exam, results, assessment, and plan. Navigate client electronic health record (EHR) to enter clinical reports and data directly into client's EHR. Document clinical reports and data into EHR in adherence with client's guidelines, workflows and note templates.

• Manages incoming or outgoing telephone calls, eReviews, and/or faxes, including triage, opening of cases and data entry into client system.

• Determines contract; verifies eligibility and benefits.

• Checks benefits for facility-based treatment.

• Obtains intake (demographic) information from caller, eReview and/or from fax. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization.

• Performs data entry of contact into client systems and routes as appropriate

• Match fax/clinical records with appropriate case.

• Consolidate inputs for approval.

• Generate needed letters.

• Assign cases/activities and work within client's system to facilitate workflow and productivity goals. • Refers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete, correct, and “nurse ready”.

• Tasks cases accurately to the correct queue.

• Responsible for reporting known or suspected data disclosures on the day of discovery to a Team Lead or to the Compliance Department.

• Performs data entry of contact into client systems and routes as appropriate

• Match fax/clinical records with appropriate case.

• Consolidate inputs for approval.

• Obtains intake (demographic) information from caller, eReview and/or from fax. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization.

• Tasks cases accurately to the correct queue.

• Conducts a thorough provider radius search in client system and follows up with provider on referrals given.

• Provide administrative support to /Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications.

• Provide administrative support of post service claims utilizing the member's benefit contract and health plan guidelines.

• Assisted customers in navigating company website and placing online orders, improving overall user experience.
• Fostered a customer-centric culture within the team by consistently reinforcing the importance of empathy, understanding, and patience in all interactions with clients.
• Ensure all Customer concerns are completed to customer's satisfaction, including exchanges.
• Follow through on all unresolved customer issues until they are satisfied.