Evelyn Uhl

Reviewed utilization management requests for compliance with established guidelines.

• Analyzed medical records and authorizations to assess if for inpatient, outpatient, behavioral health or pharmacy services.
• Received and assessed written and phone inquiries to determine necessity for clinical review, set up preauthorization for review, and ensured required documentation was completed and sent to nurses for medical necessity evaluation.
• Taking peer-to-peer calls on denied authorizations and setting up the peer-to-peer discussions between our medical directors and the requesting providers. Documenting all necessary information and sending notification to the medical director and nurses of the P2P appointment.
• Processed and managed medical records by requesting necessary documents for claims and ensuring incoming records were accurately attached to files and directed to the appropriate nurses.
• Collaborated with healthcare providers to gather necessary patient information.
• Clarified benefit eligibility and coverage details to members, enhancing their understanding of available options.
• Handled customer service inquiries sent via email or through our Dynamics system for rush requests from providers or members asking for an urgent review, status updates or questions on denials.
• Completed various reports and tasks to maintain timely work queues.

• Conducted regular quality control reviews to ensure standards were met during task execution within set timelines.
• Reviewed accuracy of data entry by all keyers to ensure adherence to quality standards.
• Ensured high-quality data entry by conducting thorough reviews of department outputs.
• Identified and communicated customer service issues during quality control reviews to enhance service quality.

• Executed precise data entry for medical, dental, and backend documents to maintain data integrity.
• Monitored workflow processes to ensure timely completion of data entry tasks, enhancing overall operational efficiency.
• Ensured compliance with established procedures governing data entry operations.
• Supported team by addressing inquiries and resolving issues related to data entry activities, fostering a collaborative work environment.